|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG201457
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Distinction Transplant |
$3.62
|
| Rate for Payer: Blue Shield of California Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California EPN |
$3.53
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna of CA HMO |
$3.87
|
| Rate for Payer: Cigna of CA PPO |
$4.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Media |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.83
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG201457
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Blue Shield of California Commercial |
$4.30
|
| Rate for Payer: Blue Shield of California EPN |
$3.09
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.83
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG203433
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.34
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$5.22
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG203433
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Distinction Transplant |
$3.91
|
| Rate for Payer: Blue Shield of California Commercial |
$4.81
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cigna of CA HMO |
$4.17
|
| Rate for Payer: Cigna of CA PPO |
$4.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.54
|
| Rate for Payer: Dignity Health Media |
$5.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.91
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$5.22
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.26
|
| Rate for Payer: United Healthcare All Other HMO |
$3.26
|
| Rate for Payer: United Healthcare HMO Rider |
$3.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.54
|
| Rate for Payer: Vantage Medical Group Senior |
$5.54
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
OP
|
$17.04
|
|
|
Service Code
|
CPT A9581
|
| Hospital Charge Code |
NDG93574
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$28.02 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.71
|
| Rate for Payer: Blue Distinction Transplant |
$10.22
|
| Rate for Payer: Blue Shield of California Commercial |
$12.56
|
| Rate for Payer: Blue Shield of California EPN |
$9.95
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cigna of CA HMO |
$10.91
|
| Rate for Payer: Cigna of CA PPO |
$12.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.48
|
| Rate for Payer: Dignity Health Media |
$14.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.82
|
| Rate for Payer: Galaxy Health WC |
$14.48
|
| Rate for Payer: Global Benefits Group Commercial |
$10.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.09
|
| Rate for Payer: Multiplan Commercial |
$13.63
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.52
|
| Rate for Payer: United Healthcare All Other HMO |
$8.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.48
|
| Rate for Payer: Vantage Medical Group Senior |
$14.48
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
IP
|
$17.04
|
|
|
Service Code
|
CPT A9581
|
| Hospital Charge Code |
NDG93574
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.48 |
| Rate for Payer: Blue Shield of California Commercial |
$12.13
|
| Rate for Payer: Blue Shield of California EPN |
$8.72
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: Galaxy Health WC |
$14.48
|
| Rate for Payer: Global Benefits Group Commercial |
$10.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.09
|
| Rate for Payer: Multiplan Commercial |
$13.63
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
1711941
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.82
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.68
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
1711941
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: Blue Distinction Transplant |
$3.30
|
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California EPN |
$3.21
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.68
|
| Rate for Payer: Dignity Health Media |
$4.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.75
|
| Rate for Payer: United Healthcare HMO Rider |
$2.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4.68
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
IP
|
$537.12
|
|
|
Service Code
|
CPT J1458
|
| Hospital Charge Code |
1759999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.91 |
| Max. Negotiated Rate |
$456.55 |
| Rate for Payer: Blue Shield of California Commercial |
$382.43
|
| Rate for Payer: Blue Shield of California EPN |
$275.01
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cigna of CA HMO |
$375.98
|
| Rate for Payer: Cigna of CA PPO |
$375.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$214.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.85
|
| Rate for Payer: Galaxy Health WC |
$456.55
|
| Rate for Payer: Global Benefits Group Commercial |
$322.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$204.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.91
|
| Rate for Payer: Multiplan Commercial |
$429.70
|
| Rate for Payer: Networks By Design Commercial |
$268.56
|
| Rate for Payer: Prime Health Services Commercial |
$456.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$202.82
|
| Rate for Payer: United Healthcare All Other HMO |
$198.09
|
| Rate for Payer: United Healthcare HMO Rider |
$193.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.25
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$537.12
|
|
|
Service Code
|
CPT J1458
|
| Hospital Charge Code |
1759999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.91 |
| Max. Negotiated Rate |
$2,911.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,911.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$578.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$509.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$509.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$643.79
|
| Rate for Payer: Blue Distinction Transplant |
$322.27
|
| Rate for Payer: Blue Shield of California Commercial |
$395.86
|
| Rate for Payer: Blue Shield of California EPN |
$468.72
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cigna of CA HMO |
$375.98
|
| Rate for Payer: Cigna of CA PPO |
$375.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$694.49
|
| Rate for Payer: Dignity Health Media |
$462.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$509.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$625.04
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$462.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$462.99
|
| Rate for Payer: Galaxy Health WC |
$456.55
|
| Rate for Payer: Global Benefits Group Commercial |
$322.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$402.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$759.31
|
| Rate for Payer: Heritage Provider Network Transplant |
$759.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$750.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$750.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$462.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$888.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$462.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$583.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$620.41
|
| Rate for Payer: Multiplan Commercial |
$429.70
|
| Rate for Payer: Networks By Design Commercial |
$268.56
|
| Rate for Payer: Prime Health Services Commercial |
$456.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$322.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$322.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$268.56
|
| Rate for Payer: United Healthcare All Other HMO |
$268.56
|
| Rate for Payer: United Healthcare HMO Rider |
$268.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$268.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$694.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$509.29
|
| Rate for Payer: Vantage Medical Group Senior |
$462.99
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$106.43
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
1740429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.54 |
| Max. Negotiated Rate |
$90.47 |
| Rate for Payer: Blue Shield of California Commercial |
$75.78
|
| Rate for Payer: Blue Shield of California EPN |
$54.49
|
| Rate for Payer: Cash Price |
$47.89
|
| Rate for Payer: Cigna of CA HMO |
$74.50
|
| Rate for Payer: Cigna of CA PPO |
$74.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.57
|
| Rate for Payer: Galaxy Health WC |
$90.47
|
| Rate for Payer: Global Benefits Group Commercial |
$63.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.54
|
| Rate for Payer: Multiplan Commercial |
$85.14
|
| Rate for Payer: Networks By Design Commercial |
$69.18
|
| Rate for Payer: Prime Health Services Commercial |
$90.47
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
OP
|
$106.43
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
1740429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.54 |
| Max. Negotiated Rate |
$90.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$69.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$58.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$63.41
|
| Rate for Payer: Blue Distinction Transplant |
$63.86
|
| Rate for Payer: Blue Shield of California Commercial |
$78.44
|
| Rate for Payer: Blue Shield of California EPN |
$62.16
|
| Rate for Payer: Cash Price |
$47.89
|
| Rate for Payer: Cigna of CA HMO |
$74.50
|
| Rate for Payer: Cigna of CA PPO |
$74.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.47
|
| Rate for Payer: Dignity Health Media |
$90.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$42.57
|
| Rate for Payer: Galaxy Health WC |
$90.47
|
| Rate for Payer: Global Benefits Group Commercial |
$63.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$79.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.54
|
| Rate for Payer: Multiplan Commercial |
$85.14
|
| Rate for Payer: Networks By Design Commercial |
$69.18
|
| Rate for Payer: Prime Health Services Commercial |
$90.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$53.22
|
| Rate for Payer: United Healthcare All Other HMO |
$53.22
|
| Rate for Payer: United Healthcare HMO Rider |
$53.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.47
|
| Rate for Payer: Vantage Medical Group Senior |
$90.47
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-01
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$69.77 |
| Rate for Payer: Blue Shield of California Commercial |
$58.44
|
| Rate for Payer: Blue Shield of California EPN |
$42.02
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| 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 Medi-Cal |
$31.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.70
|
| Rate for Payer: Multiplan Commercial |
$65.66
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.99
|
| Rate for Payer: United Healthcare All Other HMO |
$30.27
|
| Rate for Payer: United Healthcare HMO Rider |
$29.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.09
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-10
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$69.77 |
| Rate for Payer: Blue Shield of California Commercial |
$58.44
|
| Rate for Payer: Blue Shield of California EPN |
$42.02
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| 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 Medi-Cal |
$31.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.70
|
| Rate for Payer: Multiplan Commercial |
$65.66
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.99
|
| Rate for Payer: United Healthcare All Other HMO |
$30.27
|
| Rate for Payer: United Healthcare HMO Rider |
$29.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.09
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-10
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$69.77 |
| 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 Medi-Cal |
$45.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.90
|
| Rate for Payer: Blue Distinction Transplant |
$49.25
|
| Rate for Payer: Blue Shield of California Commercial |
$60.49
|
| Rate for Payer: Blue Shield of California EPN |
$47.93
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Media |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$61.56
|
| 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: LLUH Dept of Risk Management WC |
$19.70
|
| Rate for Payer: Multiplan Commercial |
$65.66
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.04
|
| Rate for Payer: United Healthcare All Other HMO |
$41.04
|
| Rate for Payer: United Healthcare HMO Rider |
$41.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-01
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$69.77 |
| 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 Medi-Cal |
$45.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.90
|
| Rate for Payer: Blue Distinction Transplant |
$49.25
|
| Rate for Payer: Blue Shield of California Commercial |
$60.49
|
| Rate for Payer: Blue Shield of California EPN |
$47.93
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Media |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$61.56
|
| 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: LLUH Dept of Risk Management WC |
$19.70
|
| Rate for Payer: Multiplan Commercial |
$65.66
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.04
|
| Rate for Payer: United Healthcare All Other HMO |
$41.04
|
| Rate for Payer: United Healthcare HMO Rider |
$41.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$18,027.22
|
|
|
Service Code
|
APR-DRG 2321
|
| Min. Negotiated Rate |
$13,828.77 |
| Max. Negotiated Rate |
$18,027.22 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,828.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,027.22
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$29,107.79
|
|
|
Service Code
|
APR-DRG 2323
|
| Min. Negotiated Rate |
$22,328.74 |
| Max. Negotiated Rate |
$29,107.79 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,328.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29,107.79
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$63,876.48
|
|
|
Service Code
|
APR-DRG 2324
|
| Min. Negotiated Rate |
$48,999.98 |
| Max. Negotiated Rate |
$63,876.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48,999.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63,876.48
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$22,021.06
|
|
|
Service Code
|
APR-DRG 2322
|
| Min. Negotiated Rate |
$16,892.47 |
| Max. Negotiated Rate |
$22,021.06 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,892.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,021.06
|
|
|
Gastrocnemius recession (eg, Strayer procedure)
|
Facility
|
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 27687
|
| Min. Negotiated Rate |
$624.61 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Media |
$4,044.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,632.50
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,632.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,551.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$6,551.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$624.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$9,317.75
|
|
|
Service Code
|
APR-DRG 2461
|
| Min. Negotiated Rate |
$7,147.70 |
| Max. Negotiated Rate |
$9,317.75 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,147.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,317.75
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$16,668.76
|
|
|
Service Code
|
APR-DRG 2463
|
| Min. Negotiated Rate |
$12,786.69 |
| Max. Negotiated Rate |
$16,668.76 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,786.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,668.76
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$24,096.01
|
|
|
Service Code
|
APR-DRG 2464
|
| Min. Negotiated Rate |
$18,484.18 |
| Max. Negotiated Rate |
$24,096.01 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,484.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,096.01
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$11,793.51
|
|
|
Service Code
|
APR-DRG 2462
|
| Min. Negotiated Rate |
$9,046.86 |
| Max. Negotiated Rate |
$11,793.51 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,046.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,793.51
|
|
