|
INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES
|
Facility
|
IP
|
$13,931.52
|
|
|
Service Code
|
APR-DRG 2283
|
| Min. Negotiated Rate |
$13,931.52 |
| Max. Negotiated Rate |
$13,931.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,931.52
|
|
|
INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES
|
Facility
|
IP
|
$7,933.30
|
|
|
Service Code
|
APR-DRG 2281
|
| Min. Negotiated Rate |
$7,933.30 |
| Max. Negotiated Rate |
$7,933.30 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,933.30
|
|
|
INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES
|
Facility
|
IP
|
$23,967.05
|
|
|
Service Code
|
APR-DRG 2284
|
| Min. Negotiated Rate |
$23,967.05 |
| Max. Negotiated Rate |
$23,967.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,967.05
|
|
|
Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64520
|
| Min. Negotiated Rate |
$130.68 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$130.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64510
|
| Min. Negotiated Rate |
$94.66 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$94.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Injection, anterior chamber of eye (separate procedure); medication
|
Facility
|
OP
|
$5,532.10
|
|
|
Service Code
|
CPT 66030
|
| Min. Negotiated Rate |
$89.43 |
| Max. Negotiated Rate |
$5,532.10 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,911.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,202.79
|
| Rate for Payer: Dignity Health Senior |
$2,911.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,911.63
|
| Rate for Payer: Humana Medicare |
$2,911.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$89.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,911.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,532.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,435.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,668.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,668.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,202.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2,911.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2,911.63
|
|
|
Injection, intralesional; up to and including 7 lesions
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11900
|
| Min. Negotiated Rate |
$33.10 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.10
|
| 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
|
|
|
Injection procedure for hip arthrography; with anesthesia
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27095
|
| Min. Negotiated Rate |
$322.34 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$322.34
|
|
|
Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27096
|
| Min. Negotiated Rate |
$458.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$458.23
|
|
|
Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT G0260
|
| Min. Negotiated Rate |
$864.04 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of radiologic service
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 50690
|
| Min. Negotiated Rate |
$419.33 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$419.33
|
|
|
Injection procedure; radioactive tracer for identification of sentinel node
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 38792
|
| Min. Negotiated Rate |
$515.32 |
| 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 |
$772.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$515.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$566.85
|
| Rate for Payer: Dignity Health Senior |
$515.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$515.32
|
| Rate for Payer: Humana Medicare |
$515.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$515.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$979.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$649.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$649.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$566.85
|
| Rate for Payer: TriValley Medical Group Senior |
$515.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Vantage Medical Group Senior |
$515.32
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64417
|
| Min. Negotiated Rate |
$101.63 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$101.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64415
|
| Min. Negotiated Rate |
$112.68 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$112.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64447
|
| Min. Negotiated Rate |
$76.66 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$137.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$76.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64454
|
| Min. Negotiated Rate |
$304.23 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$304.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64425
|
| Min. Negotiated Rate |
$107.45 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$107.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64421
|
| Min. Negotiated Rate |
$131.84 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$131.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64420
|
| Min. Negotiated Rate |
$92.93 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$92.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64450
|
| Min. Negotiated Rate |
$76.66 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$76.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64435
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$113.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64430
|
| Min. Negotiated Rate |
$109.18 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$109.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64445
|
| Min. Negotiated Rate |
$122.55 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$122.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64418
|
| Min. Negotiated Rate |
$94.66 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$94.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$864.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64483
|
| Min. Negotiated Rate |
$223.61 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$223.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
