|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN STERILE WATER INTRAVENOUS SOLN [221109]
|
Facility
OP
|
$1.55
|
|
|
Service Code
|
CPT J1806
|
| Hospital Charge Code |
NDG221109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$7.66 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Humana Medicare |
$0.45
|
| Rate for Payer: IEHP Medi-Cal |
$7.66
|
| Rate for Payer: IEHP Medicare Advantage |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN STERILE WATER INTRAVENOUS SOLN [221109]
|
Facility
IP
|
$1.55
|
|
|
Service Code
|
CPT J1806
|
| Hospital Charge Code |
NDG221109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
OP
|
$0.79
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: IEHP Medi-Cal |
$7.36
|
| Rate for Payer: IEHP Medi-Cal |
$7.36
|
| Rate for Payer: IEHP Medi-Cal |
$7.36
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
OP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
1711865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.84
|
| Rate for Payer: Blue Shield of California EPN |
$6.46
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.36
|
| Rate for Payer: Dignity Health Senior |
$9.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.82
|
| Rate for Payer: Heritage Provider Network Senior |
$6.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.36
|
| Rate for Payer: Vantage Medical Group Senior |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
1711865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
|
|
ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]
|
Facility
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5040-54
|
| Hospital Charge Code |
1711866
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
|
|
ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]
|
Facility
OP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5040-54
|
| Hospital Charge Code |
1711866
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.84
|
| Rate for Payer: Blue Shield of California EPN |
$6.46
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.36
|
| Rate for Payer: Dignity Health Senior |
$9.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.82
|
| Rate for Payer: Heritage Provider Network Senior |
$6.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.36
|
| Rate for Payer: Vantage Medical Group Senior |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM DR 10 MG GRANULES DELAYED RELEASE FOR SUSP [91031]
|
Facility
OP
|
$11.49
|
|
|
Service Code
|
NDC 0186-4010-01
|
| Hospital Charge Code |
ERX91031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Blue Shield of California Commercial |
$7.14
|
| Rate for Payer: Blue Shield of California EPN |
$6.74
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.77
|
| Rate for Payer: Dignity Health Senior |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.11
|
| Rate for Payer: Heritage Provider Network Senior |
$7.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Vantage Medical Group Senior |
$9.77
|
|
|
ESOMEPRAZOLE MAGNESIUM DR 10 MG GRANULES DELAYED RELEASE FOR SUSP [91031]
|
Facility
IP
|
$11.49
|
|
|
Service Code
|
NDC 0186-4010-01
|
| Hospital Charge Code |
ERX91031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.78
|
| Rate for Payer: Heritage Provider Network Senior |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
|
|
ESOMEPRAZOLE SODIUM 40 MG INTRAVENOUS SOLUTION [41174]
|
Facility
OP
|
$53.58
|
|
|
Service Code
|
CPT C9113
|
| Hospital Charge Code |
1722037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Adventist Health Commercial |
$10.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$45.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$29.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$40.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$63.86
|
| Rate for Payer: Blue Shield of California Commercial |
$33.27
|
| Rate for Payer: Blue Shield of California EPN |
$31.45
|
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.54
|
| Rate for Payer: Dignity Health Senior |
$45.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.81
|
| Rate for Payer: Heritage Provider Network Senior |
$24.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.40
|
| Rate for Payer: Multiplan Commercial |
$40.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.54
|
| Rate for Payer: Vantage Medical Group Senior |
$45.54
|
|
|
ESOMEPRAZOLE SODIUM 40 MG INTRAVENOUS SOLUTION [41174]
|
Facility
IP
|
$53.58
|
|
|
Service Code
|
CPT C9113
|
| Hospital Charge Code |
1722037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$40.18 |
| Rate for Payer: Adventist Health Commercial |
$10.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.81
|
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.27
|
| Rate for Payer: Heritage Provider Network Senior |
$36.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.40
|
| Rate for Payer: Multiplan Commercial |
$40.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.90
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43235
|
| Min. Negotiated Rate |
$349.63 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: IEHP Medi-Cal |
$349.63
|
| Rate for Payer: IEHP Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,132.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43239
|
| Min. Negotiated Rate |
$365.32 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: IEHP Medi-Cal |
$365.32
|
| Rate for Payer: IEHP Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,132.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43245
|
| Min. Negotiated Rate |
$377.52 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: IEHP Medi-Cal |
$377.52
|
| Rate for Payer: IEHP Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43246
|
| Min. Negotiated Rate |
$377.52 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: IEHP Medi-Cal |
$377.52
|
| Rate for Payer: IEHP Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43248
|
| Min. Negotiated Rate |
$230.57 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: IEHP Medi-Cal |
$230.57
|
| Rate for Payer: IEHP Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,132.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
|
Facility
OP
|
$13,529.58
|
|
|
Service Code
|
CPT 43266
|
| Min. Negotiated Rate |
$312.47 |
| Max. Negotiated Rate |
$13,529.58 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,681.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,832.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,120.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,681.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,832.91
|
| Rate for Payer: Dignity Health Senior |
$7,120.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,120.83
|
| Rate for Payer: Humana Medicare |
$7,120.83
|
| Rate for Payer: IEHP Medi-Cal |
$312.47
|
| Rate for Payer: IEHP Medicare Advantage |
$7,120.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,529.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,402.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,972.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,972.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,832.91
|
| Rate for Payer: TriValley Medical Group Senior |
$7,120.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,681.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,832.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7,120.83
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43247
|
| Min. Negotiated Rate |
$398.42 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: IEHP Medi-Cal |
$398.42
|
| Rate for Payer: IEHP Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,132.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43249
|
| Min. Negotiated Rate |
$347.90 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: IEHP Medi-Cal |
$347.90
|
| Rate for Payer: IEHP Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43197
|
| Min. Negotiated Rate |
$108.03 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: IEHP Medi-Cal |
$108.03
|
| Rate for Payer: IEHP Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,132.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
Esophagoscopy, flexible, transnasal; with biopsy, single or multiple
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43198
|
| Min. Negotiated Rate |
$128.36 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: IEHP Medi-Cal |
$128.36
|
| Rate for Payer: IEHP Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,132.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
Esophagoscopy, flexible, transoral; with biopsy, single or multiple
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43202
|
| Min. Negotiated Rate |
$282.84 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: IEHP Medi-Cal |
$282.84
|
| Rate for Payer: IEHP Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43214
|
| Min. Negotiated Rate |
$264.84 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: IEHP Medi-Cal |
$264.84
|
| Rate for Payer: IEHP Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43201
|
| Min. Negotiated Rate |
$326.70 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: IEHP Medi-Cal |
$326.70
|
| Rate for Payer: IEHP Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
