|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
IP
|
$611.76
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.35 |
| Max. Negotiated Rate |
$520.00 |
| Rate for Payer: Adventist Health Commercial |
$122.35
|
| Rate for Payer: Blue Shield of California Commercial |
$310.16
|
| Rate for Payer: Blue Shield of California Commercial |
$470.44
|
| Rate for Payer: Cash Price |
$275.29
|
| Rate for Payer: Cigna of CA HMO |
$428.23
|
| Rate for Payer: Cigna of CA PPO |
$428.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$428.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.70
|
| Rate for Payer: EPIC Health Plan Senior |
$244.70
|
| Rate for Payer: Galaxy Health WC |
$520.00
|
| Rate for Payer: Global Benefits Group Commercial |
$367.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$388.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$360.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.82
|
| Rate for Payer: Multiplan Commercial |
$489.41
|
| Rate for Payer: Networks By Design Commercial |
$305.88
|
| Rate for Payer: Prime Health Services Commercial |
$520.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$229.59
|
| Rate for Payer: United Healthcare All Other HMO |
$223.48
|
| Rate for Payer: United Healthcare HMO Rider |
$218.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.35
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$611.76
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.35 |
| Max. Negotiated Rate |
$3,049.65 |
| Rate for Payer: Adventist Health Commercial |
$122.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,049.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$788.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$578.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$525.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$771.66
|
| Rate for Payer: Blue Shield of California Commercial |
$563.04
|
| Rate for Payer: Cash Price |
$275.29
|
| Rate for Payer: Cash Price |
$275.29
|
| Rate for Payer: Cigna of CA HMO |
$428.23
|
| Rate for Payer: Cigna of CA PPO |
$428.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$788.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$578.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$525.97
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$428.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$867.85
|
| Rate for Payer: EPIC Health Plan Senior |
$578.57
|
| Rate for Payer: Galaxy Health WC |
$520.00
|
| Rate for Payer: Global Benefits Group Commercial |
$367.06
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$862.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$525.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$525.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$388.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$976.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$736.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$662.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$704.80
|
| Rate for Payer: Multiplan Commercial |
$489.41
|
| Rate for Payer: Networks By Design Commercial |
$305.88
|
| Rate for Payer: Prime Health Services Commercial |
$520.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$367.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$367.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$229.59
|
| Rate for Payer: United Healthcare All Other HMO |
$223.48
|
| Rate for Payer: United Healthcare HMO Rider |
$218.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.35
|
| Rate for Payer: Upland Medical Group Pediatric |
$525.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$788.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$578.57
|
| Rate for Payer: Vantage Medical Group Senior |
$525.97
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
OP
|
$114.51
|
|
|
Service Code
|
NDC 2420853535
|
| 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: Aetna of CA HMO/PPO |
$75.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.48
|
| Rate for Payer: Cash Price |
$51.53
|
| Rate for Payer: Cigna of CA HMO |
$80.16
|
| Rate for Payer: Cigna of CA PPO |
$80.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$72.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$80.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$80.16
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.26
|
| Rate for Payer: United Healthcare All Other HMO |
$57.26
|
| Rate for Payer: United Healthcare HMO Rider |
$57.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$57.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.33
|
| Rate for Payer: Vantage Medical Group Senior |
$97.33
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$114.51
|
|
|
Service Code
|
NDC 2420853535
|
| 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 |
$58.06
|
| Rate for Payer: Blue Shield of California Commercial |
$88.06
|
| Rate for Payer: Cash Price |
$51.53
|
| Rate for Payer: Cigna of CA HMO |
$80.16
|
| Rate for Payer: Cigna of CA PPO |
$80.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$72.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.56
|
| 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
|
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 |
$89.76
|
| Rate for Payer: Blue Shield of California Commercial |
$41.61
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California Commercial |
$59.18
|
| Rate for Payer: Cash Price |
$52.52
|
| Rate for Payer: Cash Price |
$36.94
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$81.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 |
$49.25
|
| Rate for Payer: Global Benefits Group Commercial |
$70.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$52.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$48.43
|
| 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
|
|
|
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 |
$201.82 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$201.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$201.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.77
|
| 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 |
$87.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.46
|
| Rate for Payer: Blue Shield of California Commercial |
$86.40
|
| Rate for Payer: Blue Shield of California Commercial |
$86.40
|
| Rate for Payer: Cash Price |
$52.52
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cash Price |
$52.52
|
| 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: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.21
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$81.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$57.46
|
| 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 |
$32.83
|
| Rate for Payer: EPIC Health Plan Senior |
$46.69
|
| 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 |
$31.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$52.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$48.43
|
| 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
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$45,825.95
|
|
|
Service Code
|
APR-DRG 2323
|
| Min. Negotiated Rate |
$36,600.46 |
| Max. Negotiated Rate |
$45,825.95 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36,600.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45,825.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41,002.16
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$29,535.48
|
|
|
Service Code
|
APR-DRG 2322
|
| Min. Negotiated Rate |
$23,589.52 |
| Max. Negotiated Rate |
$29,535.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,589.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29,535.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26,426.48
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$92,414.06
|
|
|
Service Code
|
APR-DRG 2324
|
| Min. Negotiated Rate |
$73,809.65 |
| Max. Negotiated Rate |
$92,414.06 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$73,809.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92,414.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$82,686.27
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$25,157.63
|
|
|
Service Code
|
APR-DRG 2321
|
| Min. Negotiated Rate |
$20,093.01 |
| Max. Negotiated Rate |
$25,157.63 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,093.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25,157.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22,509.46
|
|
|
GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.28 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$552.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$624.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,302.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: Prime Health Services WC |
$6,501.60
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH CC
|
Facility
|
IP
|
$96,651.97
|
|
|
Service Code
|
MSDRG 378
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$96,651.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29,730.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$96,651.97
|
| Rate for Payer: EPIC Health Plan Senior |
$64,434.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,576.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82,007.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78,493.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$111,687.18
|
|
|
Service Code
|
MSDRG 377
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$111,687.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55,417.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$111,687.18
|
| Rate for Payer: EPIC Health Plan Senior |
$74,458.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,689.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94,764.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$90,703.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC
|
Facility
|
IP
|
$90,435.96
|
|
|
Service Code
|
MSDRG 379
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$90,435.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19,111.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$90,435.96
|
| Rate for Payer: EPIC Health Plan Senior |
$60,290.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54,809.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$76,733.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73,444.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH CC
|
Facility
|
IP
|
$93,264.48
|
|
|
Service Code
|
MSDRG 389
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$93,264.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,943.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$93,264.48
|
| Rate for Payer: EPIC Health Plan Senior |
$62,176.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56,523.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,133.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75,742.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH MCC
|
Facility
|
IP
|
$105,455.18
|
|
|
Service Code
|
MSDRG 388
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$105,455.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$44,770.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$105,455.18
|
| Rate for Payer: EPIC Health Plan Senior |
$70,303.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63,912.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$89,477.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$85,642.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC
|
Facility
|
IP
|
$88,902.79
|
|
|
Service Code
|
MSDRG 390
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$88,902.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16,491.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$88,902.79
|
| Rate for Payer: EPIC Health Plan Senior |
$59,268.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$53,880.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$75,432.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72,199.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$23,153.61
|
|
|
Service Code
|
APR-DRG 2463
|
| Min. Negotiated Rate |
$18,492.42 |
| Max. Negotiated Rate |
$23,153.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,492.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23,153.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,716.39
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$16,238.81
|
|
|
Service Code
|
APR-DRG 2462
|
| Min. Negotiated Rate |
$12,969.68 |
| Max. Negotiated Rate |
$16,238.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,969.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16,238.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14,529.46
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$44,078.02
|
|
|
Service Code
|
APR-DRG 2464
|
| Min. Negotiated Rate |
$35,204.42 |
| Max. Negotiated Rate |
$44,078.02 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35,204.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44,078.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39,438.23
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$13,228.69
|
|
|
Service Code
|
APR-DRG 2461
|
| Min. Negotiated Rate |
$10,565.55 |
| Max. Negotiated Rate |
$13,228.69 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,565.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13,228.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,836.20
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
IP
|
$268.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 |
$136.15
|
| Rate for Payer: Blue Shield of California Commercial |
$206.51
|
| Rate for Payer: Cash Price |
$120.84
|
| Rate for Payer: Cigna of CA HMO |
$187.98
|
| Rate for Payer: Cigna of CA PPO |
$187.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$187.98
|
| 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 Foundation Hospitals Commercial/Self Funded |
$170.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$158.44
|
| 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 |
$134.27
|
| Rate for Payer: Prime Health Services Commercial |
$228.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$100.78
|
| Rate for Payer: United Healthcare All Other HMO |
$98.10
|
| Rate for Payer: United Healthcare HMO Rider |
$95.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$87.95
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
OP
|
$268.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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: Cash Price |
$120.84
|
| Rate for Payer: Cigna of CA HMO |
$187.98
|
| Rate for Payer: Cigna of CA PPO |
$187.98
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$187.98
|
| 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 Foundation Hospitals Commercial/Self Funded |
$170.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$158.44
|
| 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 |
$134.27
|
| 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 |
$100.78
|
| Rate for Payer: United Healthcare All Other HMO |
$98.10
|
| Rate for Payer: United Healthcare HMO Rider |
$95.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$87.95
|
| 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 IMPLANT FILM [111340]
|
Facility
|
IP
|
$2,692.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$538.46 |
| Max. Negotiated Rate |
$2,288.44 |
| Rate for Payer: Adventist Health Commercial |
$538.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1,364.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2,070.36
|
| Rate for Payer: Cash Price |
$1,211.53
|
| Rate for Payer: Cigna of CA HMO |
$1,884.60
|
| Rate for Payer: Cigna of CA PPO |
$1,884.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,884.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,076.91
|
| Rate for Payer: EPIC Health Plan Senior |
$1,076.91
|
| Rate for Payer: Galaxy Health WC |
$2,288.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1,615.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,709.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,588.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$646.15
|
| Rate for Payer: Multiplan Commercial |
$2,153.82
|
| Rate for Payer: Networks By Design Commercial |
$1,346.14
|
| Rate for Payer: Prime Health Services Commercial |
$2,288.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,010.41
|
| Rate for Payer: United Healthcare All Other HMO |
$983.49
|
| Rate for Payer: United Healthcare HMO Rider |
$962.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$881.72
|
|
|
GELATIN ABSORBABLE IMPLANT FILM [111340]
|
Facility
|
OP
|
$2,692.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$538.46 |
| Max. Negotiated Rate |
$2,288.44 |
| Rate for Payer: Adventist Health Commercial |
$538.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,765.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,288.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,480.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,019.21
|
| Rate for Payer: Cash Price |
$1,211.53
|
| Rate for Payer: Cigna of CA HMO |
$1,884.60
|
| Rate for Payer: Cigna of CA PPO |
$1,884.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,288.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,288.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,288.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,884.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,076.91
|
| Rate for Payer: EPIC Health Plan Senior |
$1,076.91
|
| Rate for Payer: Galaxy Health WC |
$2,288.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1,615.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,709.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,588.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$646.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,884.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,884.60
|
| Rate for Payer: Multiplan Commercial |
$2,153.82
|
| Rate for Payer: Networks By Design Commercial |
$1,346.14
|
| Rate for Payer: Prime Health Services Commercial |
$2,288.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,615.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,615.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,010.41
|
| Rate for Payer: United Healthcare All Other HMO |
$983.49
|
| Rate for Payer: United Healthcare HMO Rider |
$962.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$881.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,288.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,288.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2,288.44
|
|
