|
HC DRSNG GAUZE NON-ADHERENT 3X3"
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
CPT A6222
|
| Hospital Charge Code |
901607929
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
HC DRSNG GAUZE NON-ADHERENT 3X8"
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
CPT A6223
|
| Hospital Charge Code |
901607930
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.46
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.52
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Senior |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
HC DRSNG GAUZE NON-ADHERENT 3X8"
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
CPT A6223
|
| Hospital Charge Code |
901607930
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Senior |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
|
|
HC DRSNG GAUZE PETROLATM 3X36"
|
Facility
|
IP
|
$115.22
|
|
|
Service Code
|
CPT A6224
|
| Hospital Charge Code |
901698173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$97.94 |
| Rate for Payer: Adventist Health Commercial |
$23.04
|
| Rate for Payer: Cash Price |
$51.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.09
|
| Rate for Payer: EPIC Health Plan Senior |
$46.09
|
| Rate for Payer: Galaxy Health WC |
$97.94
|
| Rate for Payer: Global Benefits Group Commercial |
$69.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$76.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$71.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.65
|
| Rate for Payer: Multiplan Commercial |
$92.18
|
| Rate for Payer: Networks By Design Commercial |
$74.89
|
| Rate for Payer: Prime Health Services Commercial |
$97.94
|
|
|
HC DRSNG GAUZE PETROLATM 3X36"
|
Facility
|
OP
|
$115.22
|
|
|
Service Code
|
CPT A6224
|
| Hospital Charge Code |
901698173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$97.94 |
| Rate for Payer: Adventist Health Commercial |
$23.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$75.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.76
|
| Rate for Payer: Cash Price |
$51.85
|
| Rate for Payer: Cigna of CA HMO |
$73.74
|
| Rate for Payer: Cigna of CA PPO |
$85.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.09
|
| Rate for Payer: EPIC Health Plan Senior |
$46.09
|
| Rate for Payer: Galaxy Health WC |
$97.94
|
| Rate for Payer: Global Benefits Group Commercial |
$69.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$76.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$71.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$80.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$80.65
|
| Rate for Payer: Multiplan Commercial |
$92.18
|
| Rate for Payer: Networks By Design Commercial |
$74.89
|
| Rate for Payer: Prime Health Services Commercial |
$97.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$69.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$69.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.61
|
| Rate for Payer: United Healthcare All Other HMO |
$57.61
|
| Rate for Payer: United Healthcare HMO Rider |
$57.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$57.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.94
|
| Rate for Payer: Vantage Medical Group Senior |
$97.94
|
|
|
HC DRSNG GAUZE SPONGE 3X3 HRMT
|
Facility
|
IP
|
$0.49
|
|
| Hospital Charge Code |
901692015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
HC DRSNG GAUZE SPONGE 3X3 HRMT
|
Facility
|
OP
|
$0.49
|
|
| Hospital Charge Code |
901692015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
HC DRSNG GAUZE XEROFRM 1X8"
|
Facility
|
OP
|
$2.79
|
|
|
Service Code
|
CPT A6222
|
| Hospital Charge Code |
901607927
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.71
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$2.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.37
|
| Rate for Payer: Global Benefits Group Commercial |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$2.23
|
| Rate for Payer: Networks By Design Commercial |
$1.81
|
| Rate for Payer: Prime Health Services Commercial |
$2.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Vantage Medical Group Senior |
$2.37
|
|
|
HC DRSNG GAUZE XEROFRM 1X8"
|
Facility
|
IP
|
$2.79
|
|
|
Service Code
|
CPT A6222
|
| Hospital Charge Code |
901607927
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.37
|
| Rate for Payer: Global Benefits Group Commercial |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.23
|
| Rate for Payer: Networks By Design Commercial |
$1.81
|
| Rate for Payer: Prime Health Services Commercial |
$2.37
|
|
|
HC DRSNG GAUZE XEROFRM 5X9"
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
CPT A6223
|
| Hospital Charge Code |
901607928
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.67
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$3.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Senior |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.04
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.17
|
| Rate for Payer: United Healthcare All Other HMO |
$2.17
|
| Rate for Payer: United Healthcare HMO Rider |
$2.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.70
|
| Rate for Payer: Vantage Medical Group Senior |
$3.70
|
|
|
HC DRSNG GAUZE XEROFRM 5X9"
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
CPT A6223
|
| Hospital Charge Code |
901607928
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Senior |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.70
|
|
|
HC DRSNG HEMOSTAT SURGICEL 1X2
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
901603833
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$297.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$280.00
|
| Rate for Payer: Networks By Design Commercial |
$227.50
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
|
|
HC DRSNG HEMOSTAT SURGICEL 1X2
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
901603833
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$297.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$229.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$192.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$262.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$214.94
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna of CA HMO |
$224.00
|
| Rate for Payer: Cigna of CA PPO |
$259.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$297.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$297.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$297.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$245.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$245.00
|
| Rate for Payer: Multiplan Commercial |
$280.00
|
| Rate for Payer: Networks By Design Commercial |
$227.50
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$210.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$210.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$175.00
|
| Rate for Payer: United Healthcare All Other HMO |
$175.00
|
| Rate for Payer: United Healthcare HMO Rider |
$175.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$175.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$297.50
|
| Rate for Payer: Vantage Medical Group Senior |
$297.50
|
|
|
HC DRSNG HEMOSTAT SURGICEL 2X14
|
Facility
|
OP
|
$360.01
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
901604356
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$306.01 |
| Rate for Payer: Adventist Health Commercial |
$72.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$236.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$306.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$198.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$270.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$221.08
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna of CA HMO |
$230.41
|
| Rate for Payer: Cigna of CA PPO |
$266.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$306.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$306.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$306.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.00
|
| Rate for Payer: EPIC Health Plan Senior |
$144.00
|
| Rate for Payer: Galaxy Health WC |
$306.01
|
| Rate for Payer: Global Benefits Group Commercial |
$216.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$240.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$137.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$222.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$252.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$252.01
|
| Rate for Payer: Multiplan Commercial |
$288.01
|
| Rate for Payer: Networks By Design Commercial |
$234.01
|
| Rate for Payer: Prime Health Services Commercial |
$306.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$216.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$216.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO |
$180.00
|
| Rate for Payer: United Healthcare HMO Rider |
$180.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$180.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$306.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$306.01
|
| Rate for Payer: Vantage Medical Group Senior |
$306.01
|
|
|
HC DRSNG HEMOSTAT SURGICEL 2X14
|
Facility
|
IP
|
$360.01
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
901604356
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$306.01 |
| Rate for Payer: Adventist Health Commercial |
$72.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.00
|
| Rate for Payer: EPIC Health Plan Senior |
$144.00
|
| Rate for Payer: Galaxy Health WC |
$306.01
|
| Rate for Payer: Global Benefits Group Commercial |
$216.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$240.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$137.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$222.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.40
|
| Rate for Payer: Multiplan Commercial |
$288.01
|
| Rate for Payer: Networks By Design Commercial |
$234.01
|
| Rate for Payer: Prime Health Services Commercial |
$306.01
|
|
|
HC DRSNG HEMOSTAT SURGICEL 2X3
|
Facility
|
OP
|
$255.01
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
901603931
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$216.76 |
| Rate for Payer: Adventist Health Commercial |
$51.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$167.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$216.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$140.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$191.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.60
|
| Rate for Payer: Cash Price |
$114.75
|
| Rate for Payer: Cigna of CA HMO |
$163.21
|
| Rate for Payer: Cigna of CA PPO |
$188.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$216.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$216.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$216.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.00
|
| Rate for Payer: EPIC Health Plan Senior |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$216.76
|
| Rate for Payer: Global Benefits Group Commercial |
$153.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$170.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$157.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$178.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$178.51
|
| Rate for Payer: Multiplan Commercial |
$204.01
|
| Rate for Payer: Networks By Design Commercial |
$165.76
|
| Rate for Payer: Prime Health Services Commercial |
$216.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$153.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$153.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$127.50
|
| Rate for Payer: United Healthcare All Other HMO |
$127.50
|
| Rate for Payer: United Healthcare HMO Rider |
$127.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$127.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$216.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$216.76
|
| Rate for Payer: Vantage Medical Group Senior |
$216.76
|
|
|
HC DRSNG HEMOSTAT SURGICEL 2X3
|
Facility
|
IP
|
$255.01
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
901603931
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$216.76 |
| Rate for Payer: Adventist Health Commercial |
$51.00
|
| Rate for Payer: Cash Price |
$114.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.00
|
| Rate for Payer: EPIC Health Plan Senior |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$216.76
|
| Rate for Payer: Global Benefits Group Commercial |
$153.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$170.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$157.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.20
|
| Rate for Payer: Multiplan Commercial |
$204.01
|
| Rate for Payer: Networks By Design Commercial |
$165.76
|
| Rate for Payer: Prime Health Services Commercial |
$216.76
|
|
|
HC DRSNG HYDROFERA FOAM BLUE 4X5"
|
Facility
|
OP
|
$56.17
|
|
|
Service Code
|
CPT A6210
|
| Hospital Charge Code |
901698582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$47.74 |
| Rate for Payer: Adventist Health Commercial |
$11.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$36.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.49
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cigna of CA HMO |
$35.95
|
| Rate for Payer: Cigna of CA PPO |
$41.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.47
|
| Rate for Payer: EPIC Health Plan Senior |
$22.47
|
| Rate for Payer: Galaxy Health WC |
$47.74
|
| Rate for Payer: Global Benefits Group Commercial |
$33.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.32
|
| Rate for Payer: Multiplan Commercial |
$44.94
|
| Rate for Payer: Networks By Design Commercial |
$36.51
|
| Rate for Payer: Prime Health Services Commercial |
$47.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.09
|
| Rate for Payer: United Healthcare All Other HMO |
$28.09
|
| Rate for Payer: United Healthcare HMO Rider |
$28.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.74
|
| Rate for Payer: Vantage Medical Group Senior |
$47.74
|
|
|
HC DRSNG HYDROFERA FOAM BLUE 4X5"
|
Facility
|
IP
|
$56.17
|
|
|
Service Code
|
CPT A6210
|
| Hospital Charge Code |
901698582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$47.74 |
| Rate for Payer: Adventist Health Commercial |
$11.23
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.47
|
| Rate for Payer: EPIC Health Plan Senior |
$22.47
|
| Rate for Payer: Galaxy Health WC |
$47.74
|
| Rate for Payer: Global Benefits Group Commercial |
$33.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.48
|
| Rate for Payer: Multiplan Commercial |
$44.94
|
| Rate for Payer: Networks By Design Commercial |
$36.51
|
| Rate for Payer: Prime Health Services Commercial |
$47.74
|
|
|
HC DRSNG HYDROGEL 2.4X2.4"
|
Facility
|
OP
|
$35.92
|
|
|
Service Code
|
CPT A6231
|
| Hospital Charge Code |
901698329
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$30.53 |
| Rate for Payer: Adventist Health Commercial |
$7.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$23.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.06
|
| Rate for Payer: Cash Price |
$16.16
|
| Rate for Payer: Cigna of CA HMO |
$22.99
|
| Rate for Payer: Cigna of CA PPO |
$26.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.37
|
| Rate for Payer: EPIC Health Plan Senior |
$14.37
|
| Rate for Payer: Galaxy Health WC |
$30.53
|
| Rate for Payer: Global Benefits Group Commercial |
$21.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$28.74
|
| Rate for Payer: Networks By Design Commercial |
$23.35
|
| Rate for Payer: Prime Health Services Commercial |
$30.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.96
|
| Rate for Payer: United Healthcare All Other HMO |
$17.96
|
| Rate for Payer: United Healthcare HMO Rider |
$17.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.53
|
| Rate for Payer: Vantage Medical Group Senior |
$30.53
|
|
|
HC DRSNG HYDROGEL 2.4X2.4"
|
Facility
|
IP
|
$35.92
|
|
|
Service Code
|
CPT A6231
|
| Hospital Charge Code |
901698329
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$30.53 |
| Rate for Payer: Adventist Health Commercial |
$7.18
|
| Rate for Payer: Cash Price |
$16.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.37
|
| Rate for Payer: EPIC Health Plan Senior |
$14.37
|
| Rate for Payer: Galaxy Health WC |
$30.53
|
| Rate for Payer: Global Benefits Group Commercial |
$21.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Multiplan Commercial |
$28.74
|
| Rate for Payer: Networks By Design Commercial |
$23.35
|
| Rate for Payer: Prime Health Services Commercial |
$30.53
|
|
|
HC DRSNG HYDROGEL MCKESSN 4X4" SQ
|
Facility
|
OP
|
$38.54
|
|
| Hospital Charge Code |
901698647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$32.76 |
| Rate for Payer: Adventist Health Commercial |
$7.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$25.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$32.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.67
|
| Rate for Payer: Cash Price |
$17.34
|
| Rate for Payer: Cigna of CA HMO |
$24.67
|
| Rate for Payer: Cigna of CA PPO |
$28.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.42
|
| Rate for Payer: EPIC Health Plan Senior |
$15.42
|
| Rate for Payer: Galaxy Health WC |
$32.76
|
| Rate for Payer: Global Benefits Group Commercial |
$23.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$25.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$30.83
|
| Rate for Payer: Networks By Design Commercial |
$25.05
|
| Rate for Payer: Prime Health Services Commercial |
$32.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.27
|
| Rate for Payer: United Healthcare All Other HMO |
$19.27
|
| Rate for Payer: United Healthcare HMO Rider |
$19.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.76
|
| Rate for Payer: Vantage Medical Group Senior |
$32.76
|
|
|
HC DRSNG HYDROGEL MCKESSN 4X4" SQ
|
Facility
|
IP
|
$38.54
|
|
| Hospital Charge Code |
901698647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$32.76 |
| Rate for Payer: Adventist Health Commercial |
$7.71
|
| Rate for Payer: Cash Price |
$17.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.42
|
| Rate for Payer: EPIC Health Plan Senior |
$15.42
|
| Rate for Payer: Galaxy Health WC |
$32.76
|
| Rate for Payer: Global Benefits Group Commercial |
$23.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$25.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.25
|
| Rate for Payer: Multiplan Commercial |
$30.83
|
| Rate for Payer: Networks By Design Commercial |
$25.05
|
| Rate for Payer: Prime Health Services Commercial |
$32.76
|
|
|
HC DRSNG INTERDRY 10X36 IN SHEET
|
Facility
|
OP
|
$262.43
|
|
| Hospital Charge Code |
901607341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.49 |
| Max. Negotiated Rate |
$223.07 |
| Rate for Payer: Adventist Health Commercial |
$52.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$172.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$223.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$144.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$196.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.16
|
| Rate for Payer: Cash Price |
$118.09
|
| Rate for Payer: Cigna of CA HMO |
$167.96
|
| Rate for Payer: Cigna of CA PPO |
$194.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$223.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$223.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$223.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.97
|
| Rate for Payer: EPIC Health Plan Senior |
$104.97
|
| Rate for Payer: Galaxy Health WC |
$223.07
|
| Rate for Payer: Global Benefits Group Commercial |
$157.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$99.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$162.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$183.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$183.70
|
| Rate for Payer: Multiplan Commercial |
$209.94
|
| Rate for Payer: Networks By Design Commercial |
$170.58
|
| Rate for Payer: Prime Health Services Commercial |
$223.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$157.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$157.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$131.22
|
| Rate for Payer: United Healthcare All Other HMO |
$131.22
|
| Rate for Payer: United Healthcare HMO Rider |
$131.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$131.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$223.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$223.07
|
| Rate for Payer: Vantage Medical Group Senior |
$223.07
|
|
|
HC DRSNG INTERDRY 10X36 IN SHEET
|
Facility
|
IP
|
$262.43
|
|
| Hospital Charge Code |
901607341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.49 |
| Max. Negotiated Rate |
$223.07 |
| Rate for Payer: Adventist Health Commercial |
$52.49
|
| Rate for Payer: Cash Price |
$118.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.97
|
| Rate for Payer: EPIC Health Plan Senior |
$104.97
|
| Rate for Payer: Galaxy Health WC |
$223.07
|
| Rate for Payer: Global Benefits Group Commercial |
$157.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$99.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$162.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.98
|
| Rate for Payer: Multiplan Commercial |
$209.94
|
| Rate for Payer: Networks By Design Commercial |
$170.58
|
| Rate for Payer: Prime Health Services Commercial |
$223.07
|
|
