|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$4,508.87
|
|
|
Service Code
|
APR-DRG 4231
|
| Min. Negotiated Rate |
$4,508.87 |
| Max. Negotiated Rate |
$4,508.87 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,508.87
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$20,073.02
|
|
|
Service Code
|
APR-DRG 4234
|
| Min. Negotiated Rate |
$20,073.02 |
| Max. Negotiated Rate |
$20,073.02 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,073.02
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$5,906.69
|
|
|
Service Code
|
APR-DRG 4232
|
| Min. Negotiated Rate |
$5,906.69 |
| Max. Negotiated Rate |
$5,906.69 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,906.69
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$9,278.40
|
|
|
Service Code
|
APR-DRG 4233
|
| Min. Negotiated Rate |
$9,278.40 |
| Max. Negotiated Rate |
$9,278.40 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,278.40
|
|
|
Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11106
|
| Min. Negotiated Rate |
$211.99 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$211.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax;
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21501
|
| Min. Negotiated Rate |
$79.58 |
| 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 |
$5,325.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,905.29
|
| Rate for Payer: Dignity Health Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,550.26
|
| Rate for Payer: Humana Medicare |
$3,550.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$79.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,550.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,745.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,189.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,473.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,905.29
|
| Rate for Payer: TriValley Medical Group Senior |
$3,550.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10061
|
| Min. Negotiated Rate |
$118.19 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$118.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10060
|
| Min. Negotiated Rate |
$170.12 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$170.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$275.15
|
| Rate for Payer: TriValley Medical Group Senior |
$250.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
Incision and drainage of hematoma, seroma or fluid collection
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10140
|
| Min. Negotiated Rate |
$77.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: Dignity Health Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,025.69
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$77.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,848.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,552.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,228.26
|
| Rate for Payer: TriValley Medical Group Senior |
$2,025.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 46040
|
| Min. Negotiated Rate |
$278.77 |
| 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 |
$2,211.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,621.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,474.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,211.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,621.86
|
| Rate for Payer: Dignity Health Senior |
$1,474.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,474.42
|
| Rate for Payer: Humana Medicare |
$1,474.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$278.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,474.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,801.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,739.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,857.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,857.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,621.86
|
| Rate for Payer: TriValley Medical Group Senior |
$1,474.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,211.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,621.86
|
| Rate for Payer: Vantage Medical Group Senior |
$1,474.42
|
|
|
Incision and drainage, perianal abscess, superficial
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 46050
|
| Min. Negotiated Rate |
$124.29 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,256.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,141.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,256.12
|
| Rate for Payer: Dignity Health Senior |
$1,141.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,141.93
|
| Rate for Payer: Humana Medicare |
$1,141.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$124.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,141.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,169.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,347.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,438.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,438.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,256.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1,141.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,256.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1,141.93
|
|
|
Incision and removal of foreign body, subcutaneous tissues; complicated
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10121
|
| Min. Negotiated Rate |
$146.50 |
| 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 |
$3,038.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: Dignity Health Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,025.69
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$146.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,848.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,552.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,228.26
|
| Rate for Payer: TriValley Medical Group Senior |
$2,025.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
Incision and removal of foreign body, subcutaneous tissues; simple
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10120
|
| Min. Negotiated Rate |
$80.73 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
Incision, extensor tendon sheath, wrist (eg, de Quervains disease)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 25000
|
| Min. Negotiated Rate |
$289.24 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,012.14
|
| 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 |
$5,505.00
|
| 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 |
$289.24
|
| 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
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
OP
|
$2,665.41
|
|
|
Service Code
|
CPT J1306
|
| Hospital Charge Code |
ERX233001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$1,999.06 |
| Rate for Payer: Adventist Health Commercial |
$533.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$29.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,831.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.52
|
| Rate for Payer: Blue Shield of California Commercial |
$11.67
|
| Rate for Payer: Blue Shield of California EPN |
$11.67
|
| Rate for Payer: Cash Price |
$1,199.43
|
| Rate for Payer: Cash Price |
$1,199.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,226.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.35
|
| Rate for Payer: Dignity Health Senior |
$13.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,705.86
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,234.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1,234.08
|
| Rate for Payer: Humana Medicare |
$12.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$482.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$666.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.29
|
| Rate for Payer: Multiplan Commercial |
$1,999.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,066.16
|
| Rate for Payer: TriValley Medical Group Senior |
$1,066.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$971.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$890.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Vantage Medical Group Senior |
$13.35
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
IP
|
$2,665.41
|
|
|
Service Code
|
CPT J1306
|
| Hospital Charge Code |
ERX233001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$482.44 |
| Max. Negotiated Rate |
$1,999.06 |
| Rate for Payer: Adventist Health Commercial |
$533.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,831.14
|
| Rate for Payer: Cash Price |
$1,199.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,226.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,439.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,804.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1,804.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$482.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$666.35
|
| Rate for Payer: Multiplan Commercial |
$1,999.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$971.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$890.51
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$595.20
|
|
|
Service Code
|
CPT J0588
|
| Hospital Charge Code |
ERX105971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.73 |
| Max. Negotiated Rate |
$446.40 |
| Rate for Payer: Adventist Health Commercial |
$119.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.90
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$321.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$402.95
|
| Rate for Payer: Heritage Provider Network Senior |
$402.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.80
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.86
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$595.20
|
|
|
Service Code
|
CPT J0588
|
| Hospital Charge Code |
ERX105971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$446.40 |
| Rate for Payer: Adventist Health Commercial |
$119.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.14
|
| Rate for Payer: Blue Shield of California Commercial |
$5.14
|
| Rate for Payer: Blue Shield of California EPN |
$5.14
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.70
|
| Rate for Payer: Dignity Health Senior |
$5.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$380.93
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.58
|
| Rate for Payer: Heritage Provider Network Senior |
$275.58
|
| Rate for Payer: Humana Medicare |
$5.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.53
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$238.08
|
| Rate for Payer: TriValley Medical Group Senior |
$238.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5.19
|
|
|
INDAPAMIDE 2.5 MG TABLET [3879]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 51079-868-01
|
| Hospital Charge Code |
1710672
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: Dignity Health Senior |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
|
|
INDAPAMIDE 2.5 MG TABLET [3879]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 51079-868-01
|
| Hospital Charge Code |
1710672
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$33.92 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.61
|
| Rate for Payer: Heritage Provider Network Senior |
$30.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$33.92 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.61
|
| Rate for Payer: Heritage Provider Network Senior |
$30.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.92
|
| Rate for Payer: Blue Shield of California Commercial |
$28.08
|
| Rate for Payer: Blue Shield of California EPN |
$26.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: Dignity Health Senior |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.99
|
| Rate for Payer: Heritage Provider Network Senior |
$27.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.09
|
| Rate for Payer: TriValley Medical Group Senior |
$18.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.92
|
| Rate for Payer: Blue Shield of California Commercial |
$28.08
|
| Rate for Payer: Blue Shield of California EPN |
$26.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: Dignity Health Senior |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.99
|
| Rate for Payer: Heritage Provider Network Senior |
$27.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.09
|
| Rate for Payer: TriValley Medical Group Senior |
$18.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$33.92 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.61
|
| Rate for Payer: Heritage Provider Network Senior |
$30.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
|
