|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$114.51
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.90 |
| Max. Negotiated Rate |
$97.33 |
| Rate for Payer: Adventist Health Commercial |
$22.90
|
| Rate for Payer: Blue Shield of California Commercial |
$84.51
|
| Rate for Payer: Blue Shield of California EPN |
$55.65
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Cigna of CA HMO |
$80.16
|
| Rate for Payer: Cigna of CA PPO |
$80.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.80
|
| Rate for Payer: EPIC Health Plan Senior |
$45.80
|
| Rate for Payer: Galaxy Health WC |
$97.33
|
| Rate for Payer: Global Benefits Group Commercial |
$68.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$76.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.48
|
| Rate for Payer: Multiplan Commercial |
$91.61
|
| Rate for Payer: Networks By Design Commercial |
$74.43
|
| Rate for Payer: Prime Health Services Commercial |
$97.33
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$82.08
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.42 |
| Max. Negotiated Rate |
$188.88 |
| Rate for Payer: Blue Shield of California EPN |
$86.40
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA HMO |
$81.70
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$81.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.69
|
| Rate for Payer: EPIC Health Plan Senior |
$46.69
|
| Rate for Payer: EPIC Health Plan Senior |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Galaxy Health WC |
$99.21
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Global Benefits Group Commercial |
$70.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$77.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$81.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$81.70
|
| Rate for Payer: Multiplan Commercial |
$65.66
|
| Rate for Payer: Multiplan Commercial |
$93.38
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Networks By Design Commercial |
$58.36
|
| Rate for Payer: Prime Health Services Commercial |
$99.21
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.80
|
| Rate for Payer: United Healthcare All Other HMO |
$42.64
|
| Rate for Payer: United Healthcare All Other HMO |
$29.98
|
| Rate for Payer: United Healthcare HMO Rider |
$29.34
|
| Rate for Payer: United Healthcare HMO Rider |
$41.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$99.21
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$76.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$53.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$87.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$188.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$188.88
|
| Rate for Payer: Blue Shield of California Commercial |
$86.40
|
| Rate for Payer: Blue Shield of California Commercial |
$86.40
|
| Rate for Payer: Blue Shield of California EPN |
$86.40
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$82.08
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.42 |
| Max. Negotiated Rate |
$69.77 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Blue Shield of California Commercial |
$60.58
|
| Rate for Payer: Blue Shield of California Commercial |
$86.14
|
| Rate for Payer: Blue Shield of California EPN |
$56.73
|
| Rate for Payer: Blue Shield of California EPN |
$39.89
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA HMO |
$81.70
|
| Rate for Payer: Cigna of CA PPO |
$81.70
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Senior |
$46.69
|
| Rate for Payer: EPIC Health Plan Senior |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$99.21
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$70.03
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$77.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.70
|
| Rate for Payer: Multiplan Commercial |
$93.38
|
| Rate for Payer: Multiplan Commercial |
$65.66
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Networks By Design Commercial |
$58.36
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Prime Health Services Commercial |
$99.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.80
|
| Rate for Payer: United Healthcare All Other HMO |
$29.98
|
| Rate for Payer: United Healthcare All Other HMO |
$42.64
|
| Rate for Payer: United Healthcare HMO Rider |
$41.72
|
| Rate for Payer: United Healthcare HMO Rider |
$29.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26.88
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
OP
|
$268.54
|
|
|
Service Code
|
NDC 0009-0297-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.71 |
| Max. Negotiated Rate |
$228.26 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$176.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.91
|
| Rate for Payer: Cash Price |
$147.69
|
| Rate for Payer: Cigna of CA HMO |
$171.87
|
| Rate for Payer: Cigna of CA PPO |
$198.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.42
|
| Rate for Payer: EPIC Health Plan Senior |
$107.42
|
| Rate for Payer: Galaxy Health WC |
$228.26
|
| Rate for Payer: Global Benefits Group Commercial |
$161.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.98
|
| Rate for Payer: Multiplan Commercial |
$214.83
|
| Rate for Payer: Networks By Design Commercial |
$174.55
|
| Rate for Payer: Prime Health Services Commercial |
$228.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$161.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$161.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.27
|
| Rate for Payer: United Healthcare All Other HMO |
$134.27
|
| Rate for Payer: United Healthcare HMO Rider |
$134.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$228.26
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
IP
|
$268.54
|
|
|
Service Code
|
NDC 0009-0297-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.71 |
| Max. Negotiated Rate |
$228.26 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Blue Shield of California Commercial |
$198.18
|
| Rate for Payer: Blue Shield of California EPN |
$130.51
|
| Rate for Payer: Cash Price |
$147.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.42
|
| Rate for Payer: EPIC Health Plan Senior |
$107.42
|
| Rate for Payer: Galaxy Health WC |
$228.26
|
| Rate for Payer: Global Benefits Group Commercial |
$161.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.45
|
| Rate for Payer: Multiplan Commercial |
$214.83
|
| Rate for Payer: Networks By Design Commercial |
$174.55
|
| Rate for Payer: Prime Health Services Commercial |
$228.26
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
OP
|
$100.68
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.14 |
| Max. Negotiated Rate |
$85.58 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$66.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.83
|
| Rate for Payer: Cash Price |
$55.37
|
| Rate for Payer: Cigna of CA HMO |
$64.44
|
| Rate for Payer: Cigna of CA PPO |
$74.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.27
|
| Rate for Payer: EPIC Health Plan Senior |
$40.27
|
| Rate for Payer: Galaxy Health WC |
$85.58
|
| Rate for Payer: Global Benefits Group Commercial |
$60.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$62.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.48
|
| Rate for Payer: Multiplan Commercial |
$80.54
|
| Rate for Payer: Networks By Design Commercial |
$65.44
|
| Rate for Payer: Prime Health Services Commercial |
$85.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$50.34
|
| Rate for Payer: United Healthcare All Other HMO |
$50.34
|
| Rate for Payer: United Healthcare HMO Rider |
$50.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$50.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.58
|
| Rate for Payer: Vantage Medical Group Senior |
$85.58
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
IP
|
$100.68
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.14 |
| Max. Negotiated Rate |
$85.58 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Blue Shield of California Commercial |
$74.30
|
| Rate for Payer: Blue Shield of California EPN |
$48.93
|
| Rate for Payer: Cash Price |
$55.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.27
|
| Rate for Payer: EPIC Health Plan Senior |
$40.27
|
| Rate for Payer: Galaxy Health WC |
$85.58
|
| Rate for Payer: Global Benefits Group Commercial |
$60.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$62.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.16
|
| Rate for Payer: Multiplan Commercial |
$80.54
|
| Rate for Payer: Networks By Design Commercial |
$65.44
|
| Rate for Payer: Prime Health Services Commercial |
$85.58
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
OP
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$180.62 |
| Rate for Payer: Adventist Health Commercial |
$42.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$139.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$180.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$159.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$130.50
|
| Rate for Payer: Cash Price |
$116.88
|
| Rate for Payer: Cigna of CA HMO |
$136.00
|
| Rate for Payer: Cigna of CA PPO |
$157.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$180.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.00
|
| Rate for Payer: EPIC Health Plan Senior |
$85.00
|
| Rate for Payer: Galaxy Health WC |
$180.62
|
| Rate for Payer: Global Benefits Group Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$148.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$148.75
|
| Rate for Payer: Multiplan Commercial |
$170.00
|
| Rate for Payer: Networks By Design Commercial |
$138.12
|
| Rate for Payer: Prime Health Services Commercial |
$180.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.25
|
| Rate for Payer: United Healthcare All Other HMO |
$106.25
|
| Rate for Payer: United Healthcare HMO Rider |
$106.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$180.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.62
|
| Rate for Payer: Vantage Medical Group Senior |
$180.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
IP
|
$212.32
|
|
|
Service Code
|
NDC 85412-863-09
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$180.47 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Blue Shield of California Commercial |
$156.69
|
| Rate for Payer: Blue Shield of California EPN |
$103.19
|
| Rate for Payer: Cash Price |
$116.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.93
|
| Rate for Payer: EPIC Health Plan Senior |
$84.93
|
| Rate for Payer: Galaxy Health WC |
$180.47
|
| Rate for Payer: Global Benefits Group Commercial |
$127.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.96
|
| Rate for Payer: Multiplan Commercial |
$169.86
|
| Rate for Payer: Networks By Design Commercial |
$138.01
|
| Rate for Payer: Prime Health Services Commercial |
$180.47
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
IP
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$180.62 |
| Rate for Payer: Adventist Health Commercial |
$42.50
|
| Rate for Payer: Blue Shield of California Commercial |
$156.82
|
| Rate for Payer: Blue Shield of California EPN |
$103.28
|
| Rate for Payer: Cash Price |
$116.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.00
|
| Rate for Payer: EPIC Health Plan Senior |
$85.00
|
| Rate for Payer: Galaxy Health WC |
$180.62
|
| Rate for Payer: Global Benefits Group Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Multiplan Commercial |
$170.00
|
| Rate for Payer: Networks By Design Commercial |
$138.12
|
| Rate for Payer: Prime Health Services Commercial |
$180.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
OP
|
$212.32
|
|
|
Service Code
|
NDC 85412-863-09
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$180.47 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$139.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$180.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$159.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$130.39
|
| Rate for Payer: Cash Price |
$116.77
|
| Rate for Payer: Cigna of CA HMO |
$135.88
|
| Rate for Payer: Cigna of CA PPO |
$157.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$180.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.93
|
| Rate for Payer: EPIC Health Plan Senior |
$84.93
|
| Rate for Payer: Galaxy Health WC |
$180.47
|
| Rate for Payer: Global Benefits Group Commercial |
$127.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$148.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$148.62
|
| Rate for Payer: Multiplan Commercial |
$169.86
|
| Rate for Payer: Networks By Design Commercial |
$138.01
|
| Rate for Payer: Prime Health Services Commercial |
$180.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.16
|
| Rate for Payer: United Healthcare All Other HMO |
$106.16
|
| Rate for Payer: United Healthcare HMO Rider |
$106.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$180.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.47
|
| Rate for Payer: Vantage Medical Group Senior |
$180.47
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]
|
Facility
|
OP
|
$55.39
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$47.08 |
| Rate for Payer: Networks By Design Commercial |
$36.00
|
| Rate for Payer: Prime Health Services Commercial |
$47.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.70
|
| Rate for Payer: United Healthcare All Other HMO |
$27.70
|
| Rate for Payer: United Healthcare HMO Rider |
$27.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.08
|
| Rate for Payer: Vantage Medical Group Senior |
$47.08
|
| Rate for Payer: Adventist Health Commercial |
$11.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$36.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.01
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Cigna of CA HMO |
$35.45
|
| Rate for Payer: Cigna of CA PPO |
$40.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.16
|
| Rate for Payer: EPIC Health Plan Senior |
$22.16
|
| Rate for Payer: Galaxy Health WC |
$47.08
|
| Rate for Payer: Global Benefits Group Commercial |
$33.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$38.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$38.77
|
| Rate for Payer: Multiplan Commercial |
$44.31
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]
|
Facility
|
IP
|
$55.39
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$47.08 |
| Rate for Payer: Adventist Health Commercial |
$11.08
|
| Rate for Payer: Blue Shield of California Commercial |
$40.88
|
| Rate for Payer: Blue Shield of California EPN |
$26.92
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.16
|
| Rate for Payer: EPIC Health Plan Senior |
$22.16
|
| Rate for Payer: Galaxy Health WC |
$47.08
|
| Rate for Payer: Global Benefits Group Commercial |
$33.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.29
|
| Rate for Payer: Multiplan Commercial |
$44.31
|
| Rate for Payer: Networks By Design Commercial |
$36.00
|
| Rate for Payer: Prime Health Services Commercial |
$47.08
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]
|
Facility
|
OP
|
$106.20
|
|
|
Service Code
|
NDC 0009-0349-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.24 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$69.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.22
|
| Rate for Payer: Cash Price |
$58.41
|
| Rate for Payer: Cigna of CA HMO |
$67.97
|
| Rate for Payer: Cigna of CA PPO |
$78.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.48
|
| Rate for Payer: EPIC Health Plan Senior |
$42.48
|
| Rate for Payer: Galaxy Health WC |
$90.27
|
| Rate for Payer: Global Benefits Group Commercial |
$63.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.34
|
| Rate for Payer: Multiplan Commercial |
$84.96
|
| Rate for Payer: Networks By Design Commercial |
$69.03
|
| Rate for Payer: Prime Health Services Commercial |
$90.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$53.10
|
| Rate for Payer: United Healthcare All Other HMO |
$53.10
|
| Rate for Payer: United Healthcare HMO Rider |
$53.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.27
|
| Rate for Payer: Vantage Medical Group Senior |
$90.27
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]
|
Facility
|
IP
|
$106.20
|
|
|
Service Code
|
NDC 0009-0349-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.24 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Blue Shield of California Commercial |
$78.38
|
| Rate for Payer: Blue Shield of California EPN |
$51.61
|
| Rate for Payer: Cash Price |
$58.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.48
|
| Rate for Payer: EPIC Health Plan Senior |
$42.48
|
| Rate for Payer: Galaxy Health WC |
$90.27
|
| Rate for Payer: Global Benefits Group Commercial |
$63.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.49
|
| Rate for Payer: Multiplan Commercial |
$84.96
|
| Rate for Payer: Networks By Design Commercial |
$69.03
|
| Rate for Payer: Prime Health Services Commercial |
$90.27
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]
|
Facility
|
OP
|
$17.82
|
|
|
Service Code
|
NDC 0009-0396-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.94
|
| Rate for Payer: Cash Price |
$9.80
|
| Rate for Payer: Cigna of CA HMO |
$11.40
|
| Rate for Payer: Cigna of CA PPO |
$13.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: EPIC Health Plan Senior |
$7.13
|
| Rate for Payer: Galaxy Health WC |
$15.15
|
| Rate for Payer: Global Benefits Group Commercial |
$10.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.47
|
| Rate for Payer: Multiplan Commercial |
$14.26
|
| Rate for Payer: Networks By Design Commercial |
$11.58
|
| Rate for Payer: Prime Health Services Commercial |
$15.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.91
|
| Rate for Payer: United Healthcare All Other HMO |
$8.91
|
| Rate for Payer: United Healthcare HMO Rider |
$8.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.15
|
| Rate for Payer: Vantage Medical Group Senior |
$15.15
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]
|
Facility
|
IP
|
$17.82
|
|
|
Service Code
|
NDC 0009-0396-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$13.15
|
| Rate for Payer: Blue Shield of California EPN |
$8.66
|
| Rate for Payer: Cash Price |
$9.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: EPIC Health Plan Senior |
$7.13
|
| Rate for Payer: Galaxy Health WC |
$15.15
|
| Rate for Payer: Global Benefits Group Commercial |
$10.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Multiplan Commercial |
$14.26
|
| Rate for Payer: Networks By Design Commercial |
$11.58
|
| Rate for Payer: Prime Health Services Commercial |
$15.15
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]
|
Facility
|
OP
|
$37.05
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$31.49 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.75
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Cigna of CA HMO |
$23.71
|
| Rate for Payer: Cigna of CA PPO |
$27.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.82
|
| Rate for Payer: EPIC Health Plan Senior |
$14.82
|
| Rate for Payer: Galaxy Health WC |
$31.49
|
| Rate for Payer: Global Benefits Group Commercial |
$22.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.93
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
| Rate for Payer: Networks By Design Commercial |
$24.08
|
| Rate for Payer: Prime Health Services Commercial |
$31.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.52
|
| Rate for Payer: United Healthcare All Other HMO |
$18.52
|
| Rate for Payer: United Healthcare HMO Rider |
$18.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.49
|
| Rate for Payer: Vantage Medical Group Senior |
$31.49
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]
|
Facility
|
IP
|
$37.05
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$31.49 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California Commercial |
$27.34
|
| Rate for Payer: Blue Shield of California EPN |
$18.01
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.82
|
| Rate for Payer: EPIC Health Plan Senior |
$14.82
|
| Rate for Payer: Galaxy Health WC |
$31.49
|
| Rate for Payer: Global Benefits Group Commercial |
$22.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.89
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
| Rate for Payer: Networks By Design Commercial |
$24.08
|
| Rate for Payer: Prime Health Services Commercial |
$31.49
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
|
IP
|
$15.84
|
|
|
Service Code
|
HCPCS J9196
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.46 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California Commercial |
$11.69
|
| Rate for Payer: Blue Shield of California EPN |
$7.70
|
| Rate for Payer: Cash Price |
$8.71
|
| Rate for Payer: Cigna of CA HMO |
$11.09
|
| Rate for Payer: Cigna of CA PPO |
$11.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: EPIC Health Plan Senior |
$6.34
|
| Rate for Payer: Galaxy Health WC |
$13.46
|
| Rate for Payer: Global Benefits Group Commercial |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$12.67
|
| Rate for Payer: Networks By Design Commercial |
$7.92
|
| Rate for Payer: Prime Health Services Commercial |
$13.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.94
|
| Rate for Payer: United Healthcare All Other HMO |
$5.79
|
| Rate for Payer: United Healthcare HMO Rider |
$5.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.19
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$24.58 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.58
|
| Rate for Payer: Blue Shield of California Commercial |
$10.97
|
| Rate for Payer: Blue Shield of California EPN |
$10.97
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.66
|
| Rate for Payer: Multiplan Commercial |
$5.32
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.43
|
| Rate for Payer: United Healthcare HMO Rider |
$2.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
|
OP
|
$15.84
|
|
|
Service Code
|
HCPCS J9196
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$30.13 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.13
|
| Rate for Payer: Blue Shield of California Commercial |
$13.31
|
| Rate for Payer: Blue Shield of California EPN |
$13.31
|
| Rate for Payer: Cash Price |
$8.71
|
| Rate for Payer: Cash Price |
$8.71
|
| Rate for Payer: Cigna of CA HMO |
$11.09
|
| Rate for Payer: Cigna of CA PPO |
$11.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: EPIC Health Plan Senior |
$6.34
|
| Rate for Payer: Galaxy Health WC |
$13.46
|
| Rate for Payer: Global Benefits Group Commercial |
$9.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.09
|
| Rate for Payer: Multiplan Commercial |
$12.67
|
| Rate for Payer: Networks By Design Commercial |
$7.92
|
| Rate for Payer: Prime Health Services Commercial |
$13.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.94
|
| Rate for Payer: United Healthcare All Other HMO |
$5.79
|
| Rate for Payer: United Healthcare HMO Rider |
$5.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Vantage Medical Group Senior |
$13.46
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$5.32
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.43
|
| Rate for Payer: United Healthcare HMO Rider |
$2.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.18
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]
|
Facility
|
OP
|
$2.07
|
|
|
Service Code
|
NDC 0409-0181-01
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: EPIC Health Plan Senior |
$0.83
|
| Rate for Payer: Galaxy Health WC |
$1.76
|
| Rate for Payer: Global Benefits Group Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Networks By Design Commercial |
$1.35
|
| Rate for Payer: Prime Health Services Commercial |
$1.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.03
|
| Rate for Payer: United Healthcare All Other HMO |
$1.03
|
| Rate for Payer: United Healthcare HMO Rider |
$1.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Vantage Medical Group Senior |
$1.76
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]
|
Facility
|
IP
|
$2.07
|
|
|
Service Code
|
NDC 0409-0181-01
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: EPIC Health Plan Senior |
$0.83
|
| Rate for Payer: Galaxy Health WC |
$1.76
|
| Rate for Payer: Global Benefits Group Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Networks By Design Commercial |
$1.35
|
| Rate for Payer: Prime Health Services Commercial |
$1.76
|
|
