|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64491
|
| Min. Negotiated Rate |
$124.29 |
| Max. Negotiated Rate |
$3,237.00 |
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$124.29
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64490
|
| Min. Negotiated Rate |
$250.89 |
| 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 |
$250.89
|
| 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), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64492
|
| Min. Negotiated Rate |
$126.03 |
| Max. Negotiated Rate |
$3,237.00 |
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$126.03
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64494
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$3,237.00 |
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$113.83
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64493
|
| Min. Negotiated Rate |
$225.34 |
| 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 |
$225.34
|
| 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), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64495
|
| Min. Negotiated Rate |
$115.58 |
| Max. Negotiated Rate |
$3,237.00 |
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$115.58
|
|
|
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 62321
|
| Min. Negotiated Rate |
$348.47 |
| 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 |
$348.47
|
| 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), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 62323
|
| Min. Negotiated Rate |
$343.25 |
| 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 |
$343.25
|
| 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), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 62322
|
| Min. Negotiated Rate |
$216.06 |
| 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 |
$216.06
|
| 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), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 0232T
|
| Min. Negotiated Rate |
$497.82 |
| 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 |
$746.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$746.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.60
|
| Rate for Payer: Dignity Health Senior |
$497.82
|
| Rate for Payer: EPIC Health Plan Medicare |
$497.82
|
| Rate for Payer: Humana Medicare |
$497.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$497.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$945.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$547.60
|
| Rate for Payer: TriValley Medical Group Senior |
$497.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Vantage Medical Group Senior |
$497.82
|
|
|
Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20552
|
| Min. Negotiated Rate |
$81.88 |
| 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 |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$81.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
Injection(s); single or multiple trigger point(s), 3 or more muscles
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20553
|
| Min. Negotiated Rate |
$87.70 |
| 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 |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$87.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
Injection(s); single tendon origin/insertion
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20551
|
| Min. Negotiated Rate |
$82.02 |
| 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 |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$82.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20526
|
| Min. Negotiated Rate |
$81.88 |
| 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 |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$81.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN [219527]
|
Facility
|
OP
|
$26,288.27
|
|
|
Service Code
|
NDC 0008-0100-01
|
| Hospital Charge Code |
ERX219527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,758.18 |
| Max. Negotiated Rate |
$22,345.03 |
| Rate for Payer: Adventist Health Commercial |
$5,257.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14,051.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18,060.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22,345.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14,458.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19,716.20
|
| Rate for Payer: Blue Shield of California Commercial |
$16,325.02
|
| Rate for Payer: Blue Shield of California EPN |
$15,431.21
|
| Rate for Payer: Cash Price |
$11,829.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,092.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22,345.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$22,345.03
|
| Rate for Payer: Dignity Health Senior |
$22,345.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$16,824.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$12,171.47
|
| Rate for Payer: Heritage Provider Network Senior |
$12,171.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,670.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,758.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,572.07
|
| Rate for Payer: Multiplan Commercial |
$19,716.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,515.31
|
| Rate for Payer: TriValley Medical Group Senior |
$10,515.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,584.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,782.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22,345.03
|
| Rate for Payer: Vantage Medical Group Senior |
$22,345.03
|
|
|
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN [219527]
|
Facility
|
IP
|
$26,288.27
|
|
|
Service Code
|
NDC 0008-0100-01
|
| Hospital Charge Code |
ERX219527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,758.18 |
| Max. Negotiated Rate |
$19,716.20 |
| Rate for Payer: Adventist Health Commercial |
$5,257.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18,060.04
|
| Rate for Payer: Cash Price |
$11,829.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,092.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,195.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$17,797.16
|
| Rate for Payer: Heritage Provider Network Senior |
$17,797.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,758.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,572.07
|
| Rate for Payer: Multiplan Commercial |
$19,716.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,584.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,782.91
|
|
|
INPATIENT MS-DRG 001: HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC
|
Facility
|
IP
|
$459,359.21
|
|
|
Service Code
|
MS-DRG 001
|
| Min. Negotiated Rate |
$305,346.84 |
| Max. Negotiated Rate |
$459,359.21 |
| Rate for Payer: EPIC Health Plan Medicare |
$305,346.84
|
| Rate for Payer: Humana Medicare |
$305,346.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$305,346.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360,309.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384,737.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384,737.02
|
| Rate for Payer: Multiplan WC |
$459,359.21
|
|
|
INPATIENT MS-DRG 002: HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC
|
Facility
|
IP
|
$219,888.11
|
|
|
Service Code
|
MS-DRG 002
|
| Min. Negotiated Rate |
$138,078.46 |
| Max. Negotiated Rate |
$219,888.11 |
| Rate for Payer: EPIC Health Plan Medicare |
$138,078.46
|
| Rate for Payer: Humana Medicare |
$138,078.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$138,078.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162,932.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173,978.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173,978.86
|
| Rate for Payer: Multiplan WC |
$219,888.11
|
|
|
INPATIENT MS-DRG 003: ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$330,280.16
|
|
|
Service Code
|
MS-DRG 003
|
| Min. Negotiated Rate |
$240,280.57 |
| Max. Negotiated Rate |
$330,280.16 |
| Rate for Payer: EPIC Health Plan Medicare |
$240,280.57
|
| Rate for Payer: Humana Medicare |
$240,280.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$240,280.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$283,531.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$302,753.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$302,753.52
|
| Rate for Payer: Multiplan WC |
$330,280.16
|
|
|
INPATIENT MS-DRG 004: TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$224,108.60
|
|
|
Service Code
|
MS-DRG 004
|
| Min. Negotiated Rate |
$165,733.01 |
| Max. Negotiated Rate |
$224,108.60 |
| Rate for Payer: EPIC Health Plan Medicare |
$165,733.01
|
| Rate for Payer: Humana Medicare |
$165,733.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$165,733.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$195,564.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208,823.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208,823.59
|
| Rate for Payer: Multiplan WC |
$224,108.60
|
|
|
INPATIENT MS-DRG 005: LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$186,168.27
|
|
|
Service Code
|
MS-DRG 005
|
| Min. Negotiated Rate |
$116,750.04 |
| Max. Negotiated Rate |
$186,168.27 |
| Rate for Payer: EPIC Health Plan Medicare |
$116,750.04
|
| Rate for Payer: Humana Medicare |
$116,750.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$116,750.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137,765.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$147,105.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$147,105.05
|
| Rate for Payer: Multiplan WC |
$186,168.27
|
|
|
INPATIENT MS-DRG 006: LIVER TRANSPLANT WITHOUT MCC
|
Facility
|
IP
|
$78,490.32
|
|
|
Service Code
|
MS-DRG 006
|
| Min. Negotiated Rate |
$54,670.05 |
| Max. Negotiated Rate |
$78,490.32 |
| Rate for Payer: EPIC Health Plan Medicare |
$54,670.05
|
| Rate for Payer: Humana Medicare |
$54,670.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54,670.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64,510.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$68,884.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$68,884.26
|
| Rate for Payer: Multiplan WC |
$78,490.32
|
|
|
INPATIENT MS-DRG 007: LUNG TRANSPLANT
|
Facility
|
IP
|
$199,229.58
|
|
|
Service Code
|
MS-DRG 007
|
| Min. Negotiated Rate |
$138,329.58 |
| Max. Negotiated Rate |
$199,229.58 |
| Rate for Payer: EPIC Health Plan Medicare |
$138,329.58
|
| Rate for Payer: Humana Medicare |
$138,329.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$138,329.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$163,228.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$174,295.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$174,295.27
|
| Rate for Payer: Multiplan WC |
$199,229.58
|
|
|
INPATIENT MS-DRG 008: SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$91,249.70
|
|
|
Service Code
|
MS-DRG 008
|
| Min. Negotiated Rate |
$59,453.48 |
| Max. Negotiated Rate |
$91,249.70 |
| Rate for Payer: EPIC Health Plan Medicare |
$59,453.48
|
| Rate for Payer: Humana Medicare |
$59,453.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59,453.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70,155.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74,911.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74,911.38
|
| Rate for Payer: Multiplan WC |
$91,249.70
|
|
|
INPATIENT MS-DRG 010: PANCREAS TRANSPLANT
|
Facility
|
IP
|
$68,553.68
|
|
|
Service Code
|
MS-DRG 010
|
| Min. Negotiated Rate |
$54,407.68 |
| Max. Negotiated Rate |
$68,553.68 |
| Rate for Payer: EPIC Health Plan Medicare |
$54,407.68
|
| Rate for Payer: Humana Medicare |
$54,407.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54,407.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64,201.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$68,553.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$68,553.68
|
| Rate for Payer: Multiplan WC |
$67,677.97
|
|
