|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.67
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.44
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| 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 |
$4.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.55
|
| Rate for Payer: Blue Shield of California Commercial |
$3.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.41
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| 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 Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.12
|
| Rate for Payer: InnovAge PACE Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Riverside University Health System MISP |
$2.42
|
| 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 INTRAVENOUS SYRINGE [203433]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.87 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| 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 |
$4.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.83
|
| Rate for Payer: Blue Shield of California Commercial |
$3.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.60
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| 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 Medi-Cal |
$5.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Senior |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.12
|
| Rate for Payer: InnovAge PACE Commercial |
$3.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.56
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
| Rate for Payer: Riverside University Health System MISP |
$2.61
|
| 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
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.87 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$5.04
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Senior |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.87
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$4.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
IP
|
$17.04
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$15.34 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Blue Shield of California Commercial |
$13.17
|
| Rate for Payer: Blue Shield of California EPN |
$8.59
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Central Health Plan Commercial |
$13.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: EPIC Health Plan Senior |
$6.82
|
| Rate for Payer: Galaxy Health WC |
$14.48
|
| Rate for Payer: Global Benefits Group Commercial |
$10.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.34
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
OP
|
$17.04
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$28.02 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| 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 |
$12.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.01
|
| Rate for Payer: Blue Shield of California Commercial |
$10.41
|
| Rate for Payer: Blue Shield of California EPN |
$6.80
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Central Health Plan Commercial |
$13.63
|
| 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 Medi-Cal |
$14.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: EPIC Health Plan Senior |
$6.82
|
| Rate for Payer: Galaxy Health WC |
$14.48
|
| Rate for Payer: Global Benefits Group Commercial |
$10.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14.71
|
| Rate for Payer: InnovAge PACE Commercial |
$8.52
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
| Rate for Payer: Riverside University Health System MISP |
$6.82
|
| 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
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$2.77
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Central Health Plan Commercial |
$4.40
|
| 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: EPIC Health Plan Senior |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.67
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.95
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.23
|
| Rate for Payer: Blue Shield of California Commercial |
$3.36
|
| Rate for Payer: Blue Shield of California EPN |
$2.19
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Central Health Plan Commercial |
$4.40
|
| 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 |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.67
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.95
|
| Rate for Payer: InnovAge PACE Commercial |
$2.75
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
| Rate for Payer: Riverside University Health System MISP |
$2.20
|
| 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 |
$4.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Vantage Medical Group Senior |
$4.67
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
IP
|
$596.88
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.38 |
| Max. Negotiated Rate |
$537.19 |
| Rate for Payer: Adventist Health Commercial |
$119.38
|
| Rate for Payer: Blue Shield of California Commercial |
$461.39
|
| Rate for Payer: Blue Shield of California EPN |
$300.83
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Central Health Plan Commercial |
$477.50
|
| Rate for Payer: Cigna of CA HMO |
$417.82
|
| Rate for Payer: Cigna of CA PPO |
$417.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$238.75
|
| Rate for Payer: EPIC Health Plan Senior |
$238.75
|
| Rate for Payer: Galaxy Health WC |
$507.35
|
| Rate for Payer: Global Benefits Group Commercial |
$358.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$537.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$398.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$227.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$369.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.38
|
| Rate for Payer: Multiplan Commercial |
$447.66
|
| Rate for Payer: Networks By Design Commercial |
$298.44
|
| Rate for Payer: Prime Health Services Commercial |
$507.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$224.01
|
| Rate for Payer: United Healthcare All Other HMO |
$218.04
|
| Rate for Payer: United Healthcare HMO Rider |
$213.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$195.48
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$596.88
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.38 |
| Max. Negotiated Rate |
$1,077.95 |
| Rate for Payer: Adventist Health Commercial |
$119.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$362.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$507.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$328.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$447.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,077.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$330.83
|
| Rate for Payer: Blue Shield of California Commercial |
$619.34
|
| Rate for Payer: Blue Shield of California EPN |
$563.04
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Central Health Plan Commercial |
$477.50
|
| Rate for Payer: Cigna of CA HMO |
$417.82
|
| Rate for Payer: Cigna of CA PPO |
$417.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$507.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$507.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$507.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$238.75
|
| Rate for Payer: EPIC Health Plan Senior |
$238.75
|
| Rate for Payer: Galaxy Health WC |
$507.35
|
| Rate for Payer: Global Benefits Group Commercial |
$358.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$537.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$484.88
|
| Rate for Payer: InnovAge PACE Commercial |
$298.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$398.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$921.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$369.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$417.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$417.82
|
| Rate for Payer: Multiplan Commercial |
$447.66
|
| Rate for Payer: Networks By Design Commercial |
$298.44
|
| Rate for Payer: Prime Health Services Commercial |
$507.35
|
| Rate for Payer: Riverside University Health System MISP |
$238.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$358.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$358.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$224.01
|
| Rate for Payer: United Healthcare All Other HMO |
$218.04
|
| Rate for Payer: United Healthcare HMO Rider |
$213.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$195.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$507.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$507.35
|
| Rate for Payer: Vantage Medical Group Senior |
$507.35
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$114.51
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.90 |
| Max. Negotiated Rate |
$103.06 |
| Rate for Payer: Adventist Health Commercial |
$22.90
|
| Rate for Payer: Blue Shield of California Commercial |
$88.52
|
| Rate for Payer: Blue Shield of California EPN |
$57.71
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Central Health Plan Commercial |
$91.61
|
| Rate for Payer: Cigna of CA HMO |
$80.16
|
| Rate for Payer: Cigna of CA PPO |
$80.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.80
|
| Rate for Payer: EPIC Health Plan Senior |
$45.80
|
| Rate for Payer: Galaxy Health WC |
$97.33
|
| Rate for Payer: Global Benefits Group Commercial |
$68.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$103.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$76.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.90
|
| Rate for Payer: Multiplan Commercial |
$85.88
|
| Rate for Payer: Networks By Design Commercial |
$74.43
|
| Rate for Payer: Prime Health Services Commercial |
$97.33
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
OP
|
$114.51
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.90 |
| Max. Negotiated Rate |
$103.06 |
| Rate for Payer: Adventist Health Commercial |
$22.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$69.54
|
| 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 Exchange |
$55.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.25
|
| Rate for Payer: Blue Shield of California Commercial |
$69.97
|
| Rate for Payer: Blue Shield of California EPN |
$45.69
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Central Health Plan Commercial |
$91.61
|
| 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: 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: Health Management Network EPO/PPO |
$103.06
|
| Rate for Payer: InnovAge PACE Commercial |
$57.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$76.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.90
|
| 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 |
$85.88
|
| Rate for Payer: Networks By Design Commercial |
$74.43
|
| Rate for Payer: Prime Health Services Commercial |
$97.33
|
| Rate for Payer: Riverside University Health System MISP |
$45.80
|
| 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 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 |
$152.90 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$49.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$70.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$87.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$152.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$152.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.93
|
| Rate for Payer: Blue Shield of California Commercial |
$95.04
|
| Rate for Payer: Blue Shield of California Commercial |
$95.04
|
| Rate for Payer: Blue Shield of California EPN |
$86.40
|
| Rate for Payer: Blue Shield of California EPN |
$86.40
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Central Health Plan Commercial |
$65.66
|
| Rate for Payer: Central Health Plan Commercial |
$93.38
|
| Rate for Payer: Cigna of CA HMO |
$81.70
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$81.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.69
|
| Rate for Payer: EPIC Health Plan Senior |
$46.69
|
| Rate for Payer: EPIC Health Plan Senior |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Galaxy Health WC |
$99.21
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Global Benefits Group Commercial |
$70.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$73.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$32.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$32.09
|
| Rate for Payer: InnovAge PACE Commercial |
$58.36
|
| Rate for Payer: InnovAge PACE Commercial |
$41.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$77.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$81.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$81.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.46
|
| Rate for Payer: Multiplan Commercial |
$87.54
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Networks By Design Commercial |
$58.36
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Prime Health Services Commercial |
$99.21
|
| Rate for Payer: Riverside University Health System MISP |
$46.69
|
| Rate for Payer: Riverside University Health System MISP |
$32.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.03
|
| 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 |
$30.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.81
|
| 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
|
| 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 |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$99.21
|
|
|
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 |
$73.87 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Blue Shield of California Commercial |
$63.45
|
| Rate for Payer: Blue Shield of California Commercial |
$90.22
|
| Rate for Payer: Blue Shield of California EPN |
$58.83
|
| Rate for Payer: Blue Shield of California EPN |
$41.37
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Central Health Plan Commercial |
$65.66
|
| Rate for Payer: Central Health Plan Commercial |
$93.38
|
| Rate for Payer: Cigna of CA HMO |
$81.70
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$81.70
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Senior |
$46.69
|
| Rate for Payer: EPIC Health Plan Senior |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$99.21
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Global Benefits Group Commercial |
$70.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$73.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$77.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.34
|
| Rate for Payer: Multiplan Commercial |
$87.54
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Networks By Design Commercial |
$58.36
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Prime Health Services Commercial |
$99.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.80
|
| Rate for Payer: United Healthcare All Other HMO |
$29.98
|
| Rate for Payer: United Healthcare All Other HMO |
$42.64
|
| Rate for Payer: United Healthcare HMO Rider |
$41.72
|
| Rate for Payer: United Healthcare HMO Rider |
$29.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26.88
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
IP
|
$268.54
|
|
|
Service Code
|
NDC 0009-0297-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.71 |
| Max. Negotiated Rate |
$241.69 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Blue Shield of California Commercial |
$207.58
|
| Rate for Payer: Blue Shield of California EPN |
$135.34
|
| Rate for Payer: Cash Price |
$147.69
|
| Rate for Payer: Central Health Plan Commercial |
$214.83
|
| 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: Health Management Network EPO/PPO |
$241.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.71
|
| Rate for Payer: Multiplan Commercial |
$201.41
|
| Rate for Payer: Networks By Design Commercial |
$174.55
|
| Rate for Payer: Prime Health Services Commercial |
$228.26
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
OP
|
$268.54
|
|
|
Service Code
|
NDC 0009-0297-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.71 |
| Max. Negotiated Rate |
$241.69 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$163.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$130.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$157.71
|
| Rate for Payer: Blue Shield of California Commercial |
$164.08
|
| Rate for Payer: Blue Shield of California EPN |
$107.15
|
| Rate for Payer: Cash Price |
$147.69
|
| Rate for Payer: Central Health Plan Commercial |
$214.83
|
| Rate for Payer: Cigna of CA HMO |
$171.87
|
| Rate for Payer: Cigna of CA PPO |
$198.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.42
|
| Rate for Payer: EPIC Health Plan Senior |
$107.42
|
| Rate for Payer: Galaxy Health WC |
$228.26
|
| Rate for Payer: Global Benefits Group Commercial |
$161.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$241.69
|
| Rate for Payer: InnovAge PACE Commercial |
$134.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.71
|
| 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 |
$201.41
|
| Rate for Payer: Networks By Design Commercial |
$174.55
|
| Rate for Payer: Prime Health Services Commercial |
$228.26
|
| Rate for Payer: Riverside University Health System MISP |
$107.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$161.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$161.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.27
|
| Rate for Payer: United Healthcare All Other HMO |
$134.27
|
| Rate for Payer: United Healthcare HMO Rider |
$134.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$228.26
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
IP
|
$100.68
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.14 |
| Max. Negotiated Rate |
$90.61 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Blue Shield of California Commercial |
$77.83
|
| Rate for Payer: Blue Shield of California EPN |
$50.74
|
| Rate for Payer: Cash Price |
$55.37
|
| Rate for Payer: Central Health Plan Commercial |
$80.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.27
|
| Rate for Payer: EPIC Health Plan Senior |
$40.27
|
| Rate for Payer: Galaxy Health WC |
$85.58
|
| Rate for Payer: Global Benefits Group Commercial |
$60.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$62.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.14
|
| Rate for Payer: Multiplan Commercial |
$75.51
|
| Rate for Payer: Networks By Design Commercial |
$65.44
|
| Rate for Payer: Prime Health Services Commercial |
$85.58
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
OP
|
$100.68
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.14 |
| Max. Negotiated Rate |
$90.61 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$61.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.13
|
| Rate for Payer: Blue Shield of California Commercial |
$61.52
|
| Rate for Payer: Blue Shield of California EPN |
$40.17
|
| Rate for Payer: Cash Price |
$55.37
|
| Rate for Payer: Central Health Plan Commercial |
$80.54
|
| Rate for Payer: Cigna of CA HMO |
$64.44
|
| Rate for Payer: Cigna of CA PPO |
$74.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.27
|
| Rate for Payer: EPIC Health Plan Senior |
$40.27
|
| Rate for Payer: Galaxy Health WC |
$85.58
|
| Rate for Payer: Global Benefits Group Commercial |
$60.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.61
|
| Rate for Payer: InnovAge PACE Commercial |
$50.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$62.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.48
|
| Rate for Payer: Multiplan Commercial |
$75.51
|
| Rate for Payer: Networks By Design Commercial |
$65.44
|
| Rate for Payer: Prime Health Services Commercial |
$85.58
|
| Rate for Payer: Riverside University Health System MISP |
$40.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$50.34
|
| Rate for Payer: United Healthcare All Other HMO |
$50.34
|
| Rate for Payer: United Healthcare HMO Rider |
$50.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$50.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.58
|
| Rate for Payer: Vantage Medical Group Senior |
$85.58
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
OP
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Adventist Health Commercial |
$42.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$129.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$180.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$159.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$102.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$124.80
|
| Rate for Payer: Blue Shield of California Commercial |
$129.84
|
| Rate for Payer: Blue Shield of California EPN |
$84.79
|
| Rate for Payer: Cash Price |
$116.88
|
| Rate for Payer: Central Health Plan Commercial |
$170.00
|
| Rate for Payer: Cigna of CA HMO |
$136.00
|
| Rate for Payer: Cigna of CA PPO |
$157.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$180.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.00
|
| Rate for Payer: EPIC Health Plan Senior |
$85.00
|
| Rate for Payer: Galaxy Health WC |
$180.62
|
| Rate for Payer: Global Benefits Group Commercial |
$127.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$191.25
|
| Rate for Payer: InnovAge PACE Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$148.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$148.75
|
| Rate for Payer: Multiplan Commercial |
$159.38
|
| Rate for Payer: Networks By Design Commercial |
$138.12
|
| Rate for Payer: Prime Health Services Commercial |
$180.62
|
| Rate for Payer: Riverside University Health System MISP |
$85.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.25
|
| Rate for Payer: United Healthcare All Other HMO |
$106.25
|
| Rate for Payer: United Healthcare HMO Rider |
$106.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$180.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.62
|
| Rate for Payer: Vantage Medical Group Senior |
$180.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
IP
|
$212.32
|
|
|
Service Code
|
NDC 85412-863-09
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$191.09 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Blue Shield of California Commercial |
$164.12
|
| Rate for Payer: Blue Shield of California EPN |
$107.01
|
| Rate for Payer: Cash Price |
$116.77
|
| Rate for Payer: Central Health Plan Commercial |
$169.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.93
|
| Rate for Payer: EPIC Health Plan Senior |
$84.93
|
| Rate for Payer: Galaxy Health WC |
$180.47
|
| Rate for Payer: Global Benefits Group Commercial |
$127.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$191.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.46
|
| Rate for Payer: Multiplan Commercial |
$159.24
|
| Rate for Payer: Networks By Design Commercial |
$138.01
|
| Rate for Payer: Prime Health Services Commercial |
$180.47
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
IP
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Adventist Health Commercial |
$42.50
|
| Rate for Payer: Blue Shield of California Commercial |
$164.26
|
| Rate for Payer: Blue Shield of California EPN |
$107.10
|
| Rate for Payer: Cash Price |
$116.88
|
| Rate for Payer: Central Health Plan Commercial |
$170.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.00
|
| Rate for Payer: EPIC Health Plan Senior |
$85.00
|
| Rate for Payer: Galaxy Health WC |
$180.62
|
| Rate for Payer: Global Benefits Group Commercial |
$127.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$191.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.50
|
| Rate for Payer: Multiplan Commercial |
$159.38
|
| Rate for Payer: Networks By Design Commercial |
$138.12
|
| Rate for Payer: Prime Health Services Commercial |
$180.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
OP
|
$212.32
|
|
|
Service Code
|
NDC 85412-863-09
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$191.09 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$128.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$180.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$159.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$102.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$124.70
|
| Rate for Payer: Blue Shield of California Commercial |
$129.73
|
| Rate for Payer: Blue Shield of California EPN |
$84.72
|
| Rate for Payer: Cash Price |
$116.77
|
| Rate for Payer: Central Health Plan Commercial |
$169.86
|
| Rate for Payer: Cigna of CA HMO |
$135.88
|
| Rate for Payer: Cigna of CA PPO |
$157.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$180.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.93
|
| Rate for Payer: EPIC Health Plan Senior |
$84.93
|
| Rate for Payer: Galaxy Health WC |
$180.47
|
| Rate for Payer: Global Benefits Group Commercial |
$127.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$191.09
|
| Rate for Payer: InnovAge PACE Commercial |
$106.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$131.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$148.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$148.62
|
| Rate for Payer: Multiplan Commercial |
$159.24
|
| Rate for Payer: Networks By Design Commercial |
$138.01
|
| Rate for Payer: Prime Health Services Commercial |
$180.47
|
| Rate for Payer: Riverside University Health System MISP |
$84.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.16
|
| Rate for Payer: United Healthcare All Other HMO |
$106.16
|
| Rate for Payer: United Healthcare HMO Rider |
$106.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$180.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.47
|
| Rate for Payer: Vantage Medical Group Senior |
$180.47
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]
|
Facility
|
IP
|
$55.39
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$49.85 |
| Rate for Payer: Adventist Health Commercial |
$11.08
|
| Rate for Payer: Blue Shield of California Commercial |
$42.82
|
| Rate for Payer: Blue Shield of California EPN |
$27.92
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Central Health Plan Commercial |
$44.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.16
|
| Rate for Payer: EPIC Health Plan Senior |
$22.16
|
| Rate for Payer: Galaxy Health WC |
$47.08
|
| Rate for Payer: Global Benefits Group Commercial |
$33.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$49.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.08
|
| Rate for Payer: Multiplan Commercial |
$41.54
|
| Rate for Payer: Networks By Design Commercial |
$36.00
|
| Rate for Payer: Prime Health Services Commercial |
$47.08
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]
|
Facility
|
OP
|
$55.39
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$49.85 |
| Rate for Payer: Adventist Health Commercial |
$11.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$33.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$26.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.53
|
| Rate for Payer: Blue Shield of California Commercial |
$33.84
|
| Rate for Payer: Blue Shield of California EPN |
$22.10
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Central Health Plan Commercial |
$44.31
|
| Rate for Payer: Cigna of CA HMO |
$35.45
|
| Rate for Payer: Cigna of CA PPO |
$40.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.16
|
| Rate for Payer: EPIC Health Plan Senior |
$22.16
|
| Rate for Payer: Galaxy Health WC |
$47.08
|
| Rate for Payer: Global Benefits Group Commercial |
$33.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$49.85
|
| Rate for Payer: InnovAge PACE Commercial |
$27.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$38.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$38.77
|
| Rate for Payer: Multiplan Commercial |
$41.54
|
| Rate for Payer: Networks By Design Commercial |
$36.00
|
| Rate for Payer: Prime Health Services Commercial |
$47.08
|
| Rate for Payer: Riverside University Health System MISP |
$22.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.70
|
| Rate for Payer: United Healthcare All Other HMO |
$27.70
|
| Rate for Payer: United Healthcare HMO Rider |
$27.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.08
|
| Rate for Payer: Vantage Medical Group Senior |
$47.08
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]
|
Facility
|
IP
|
$106.20
|
|
|
Service Code
|
NDC 0009-0349-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.24 |
| Max. Negotiated Rate |
$95.58 |
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Blue Shield of California Commercial |
$82.09
|
| Rate for Payer: Blue Shield of California EPN |
$53.52
|
| Rate for Payer: Cash Price |
$58.41
|
| Rate for Payer: Central Health Plan Commercial |
$84.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.48
|
| Rate for Payer: EPIC Health Plan Senior |
$42.48
|
| Rate for Payer: Galaxy Health WC |
$90.27
|
| Rate for Payer: Global Benefits Group Commercial |
$63.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.24
|
| Rate for Payer: Multiplan Commercial |
$79.65
|
| Rate for Payer: Networks By Design Commercial |
$69.03
|
| Rate for Payer: Prime Health Services Commercial |
$90.27
|
|
