|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-01
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.42 |
| Max. Negotiated Rate |
$73.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$49.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.49
|
| Rate for Payer: Blue Distinction Transplant |
$49.25
|
| Rate for Payer: Blue Shield of California Commercial |
$51.63
|
| Rate for Payer: Blue Shield of California EPN |
$40.14
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Central Health Plan Commercial |
$65.66
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Media |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$73.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$61.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.42
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Riverside University Health System MISP |
$32.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.04
|
| Rate for Payer: United Healthcare All Other HMO |
$41.04
|
| Rate for Payer: United Healthcare HMO Rider |
$41.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-01
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.42 |
| Max. Negotiated Rate |
$73.87 |
| Rate for Payer: Blue Shield of California Commercial |
$61.56
|
| Rate for Payer: Blue Shield of California EPN |
$43.83
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Central Health Plan Commercial |
$65.66
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$73.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.42
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.99
|
| Rate for Payer: United Healthcare All Other HMO |
$30.27
|
| Rate for Payer: United Healthcare HMO Rider |
$29.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.09
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-10
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.42 |
| Max. Negotiated Rate |
$73.87 |
| Rate for Payer: Blue Shield of California Commercial |
$61.56
|
| Rate for Payer: Blue Shield of California EPN |
$43.83
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Central Health Plan Commercial |
$65.66
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$73.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.42
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.99
|
| Rate for Payer: United Healthcare All Other HMO |
$30.27
|
| Rate for Payer: United Healthcare HMO Rider |
$29.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.09
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$63,876.48
|
|
|
Service Code
|
APR-DRG 2324
|
| Min. Negotiated Rate |
$40,343.04 |
| Max. Negotiated Rate |
$63,876.48 |
| Rate for Payer: Adventist Health Medi-Cal |
$40,343.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$48,075.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63,876.48
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$22,021.06
|
|
|
Service Code
|
APR-DRG 2322
|
| Min. Negotiated Rate |
$13,908.04 |
| Max. Negotiated Rate |
$22,021.06 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,908.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$16,573.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,021.06
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$29,107.79
|
|
|
Service Code
|
APR-DRG 2323
|
| Min. Negotiated Rate |
$18,383.87 |
| Max. Negotiated Rate |
$29,107.79 |
| Rate for Payer: Adventist Health Medi-Cal |
$18,383.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$21,907.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29,107.79
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$18,027.22
|
|
|
Service Code
|
APR-DRG 2321
|
| Min. Negotiated Rate |
$11,385.61 |
| Max. Negotiated Rate |
$18,027.22 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,385.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,567.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,027.22
|
|
|
Gastrocnemius recession (eg, Strayer procedure)
|
Facility
|
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 27687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$624.61 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,044.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$4,044.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Media |
$4,044.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,632.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,672.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: InnovAge PACE Commercial |
$6,066.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$624.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,419.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Prime Health Services Medicare |
$4,286.86
|
| Rate for Payer: Riverside University Health System MISP |
$4,448.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$16,668.76
|
|
|
Service Code
|
APR-DRG 2463
|
| Min. Negotiated Rate |
$10,527.64 |
| Max. Negotiated Rate |
$16,668.76 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,527.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,545.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,668.76
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$24,096.01
|
|
|
Service Code
|
APR-DRG 2464
|
| Min. Negotiated Rate |
$15,218.53 |
| Max. Negotiated Rate |
$24,096.01 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,218.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$18,135.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,096.01
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$11,793.51
|
|
|
Service Code
|
APR-DRG 2462
|
| Min. Negotiated Rate |
$7,448.53 |
| Max. Negotiated Rate |
$11,793.51 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,448.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,876.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,793.51
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$9,317.75
|
|
|
Service Code
|
APR-DRG 2461
|
| Min. Negotiated Rate |
$5,884.90 |
| Max. Negotiated Rate |
$9,317.75 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,884.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,012.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,317.75
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
IP
|
$268.54
|
|
|
Service Code
|
NDC 0009-0297-01
|
| Hospital Charge Code |
ERX28028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.71 |
| Max. Negotiated Rate |
$241.69 |
| Rate for Payer: Blue Shield of California Commercial |
$201.40
|
| Rate for Payer: Blue Shield of California EPN |
$143.40
|
| Rate for Payer: Cash Price |
$120.84
|
| Rate for Payer: Central Health Plan Commercial |
$214.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$53.71
|
| Rate for Payer: Multiplan Commercial |
$201.40
|
| 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 |
ERX28028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.71 |
| Max. Negotiated Rate |
$241.69 |
| 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 |
$147.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$130.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$158.65
|
| Rate for Payer: Blue Distinction Transplant |
$161.12
|
| Rate for Payer: Blue Shield of California Commercial |
$168.91
|
| Rate for Payer: Blue Shield of California EPN |
$131.32
|
| Rate for Payer: Cash Price |
$120.84
|
| 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 Media |
$228.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$201.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$93.99
|
| 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: LLUH Dept of Risk Management WC |
$53.71
|
| Rate for Payer: Multiplan Commercial |
$201.40
|
| 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 Medi-Cal |
$228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$228.26
|
|
|
GELATIN ABSORBABLE IMPLANT FILM [111340]
|
Facility
|
IP
|
$2,441.98
|
|
|
Service Code
|
NDC 0009-0283-01
|
| Hospital Charge Code |
1780004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$488.40 |
| Max. Negotiated Rate |
$2,197.78 |
| Rate for Payer: Blue Shield of California Commercial |
$1,831.48
|
| Rate for Payer: Blue Shield of California EPN |
$1,304.02
|
| Rate for Payer: Cash Price |
$1,098.89
|
| Rate for Payer: Central Health Plan Commercial |
$1,953.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$976.79
|
| Rate for Payer: Galaxy Health WC |
$2,075.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1,465.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,197.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,628.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$930.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$488.40
|
| Rate for Payer: Multiplan Commercial |
$1,831.48
|
| Rate for Payer: Networks By Design Commercial |
$1,587.29
|
| Rate for Payer: Prime Health Services Commercial |
$2,075.68
|
|
|
GELATIN ABSORBABLE IMPLANT FILM [111340]
|
Facility
|
OP
|
$2,441.98
|
|
|
Service Code
|
NDC 0009-0283-01
|
| Hospital Charge Code |
1780004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$488.40 |
| Max. Negotiated Rate |
$2,197.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,483.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,075.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,343.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,343.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,182.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,442.72
|
| Rate for Payer: Blue Distinction Transplant |
$1,465.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1,536.01
|
| Rate for Payer: Blue Shield of California EPN |
$1,194.13
|
| Rate for Payer: Cash Price |
$1,098.89
|
| Rate for Payer: Central Health Plan Commercial |
$1,953.58
|
| Rate for Payer: Cigna of CA HMO |
$1,562.87
|
| Rate for Payer: Cigna of CA PPO |
$1,807.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,075.68
|
| Rate for Payer: Dignity Health Media |
$2,075.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,075.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$976.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$976.79
|
| Rate for Payer: Galaxy Health WC |
$2,075.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1,465.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,197.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,831.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$854.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,628.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$930.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$488.40
|
| Rate for Payer: Multiplan Commercial |
$1,831.48
|
| Rate for Payer: Networks By Design Commercial |
$1,587.29
|
| Rate for Payer: Prime Health Services Commercial |
$2,075.68
|
| Rate for Payer: Riverside University Health System MISP |
$976.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,465.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,465.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,220.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1,220.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1,220.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,220.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,075.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,075.68
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
OP
|
$91.32
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
1743583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.26 |
| Max. Negotiated Rate |
$82.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$77.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$50.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$44.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.95
|
| Rate for Payer: Blue Distinction Transplant |
$54.79
|
| Rate for Payer: Blue Shield of California Commercial |
$57.44
|
| Rate for Payer: Blue Shield of California EPN |
$44.66
|
| Rate for Payer: Cash Price |
$41.09
|
| Rate for Payer: Central Health Plan Commercial |
$73.06
|
| Rate for Payer: Cigna of CA HMO |
$58.44
|
| Rate for Payer: Cigna of CA PPO |
$67.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$77.62
|
| Rate for Payer: Dignity Health Media |
$77.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$77.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.53
|
| Rate for Payer: Galaxy Health WC |
$77.62
|
| Rate for Payer: Global Benefits Group Commercial |
$54.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$82.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$68.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$31.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.26
|
| Rate for Payer: Multiplan Commercial |
$68.49
|
| Rate for Payer: Networks By Design Commercial |
$59.36
|
| Rate for Payer: Prime Health Services Commercial |
$77.62
|
| Rate for Payer: Riverside University Health System MISP |
$36.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$54.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$54.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.66
|
| Rate for Payer: United Healthcare All Other HMO |
$45.66
|
| Rate for Payer: United Healthcare HMO Rider |
$45.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$77.62
|
| Rate for Payer: Vantage Medical Group Senior |
$77.62
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
IP
|
$91.32
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
1743583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.26 |
| Max. Negotiated Rate |
$82.19 |
| Rate for Payer: Blue Shield of California Commercial |
$68.49
|
| Rate for Payer: Blue Shield of California EPN |
$48.76
|
| Rate for Payer: Cash Price |
$41.09
|
| Rate for Payer: Central Health Plan Commercial |
$73.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.53
|
| Rate for Payer: Galaxy Health WC |
$77.62
|
| Rate for Payer: Global Benefits Group Commercial |
$54.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$82.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.26
|
| Rate for Payer: Multiplan Commercial |
$68.49
|
| Rate for Payer: Networks By Design Commercial |
$59.36
|
| Rate for Payer: Prime Health Services Commercial |
$77.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
IP
|
$212.32
|
|
|
Service Code
|
NDC 85412-863-09
|
| Hospital Charge Code |
1796131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$191.09 |
| Rate for Payer: Blue Shield of California Commercial |
$159.24
|
| Rate for Payer: Blue Shield of California EPN |
$113.38
|
| Rate for Payer: Cash Price |
$95.54
|
| Rate for Payer: Central Health Plan Commercial |
$169.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
OP
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
1796131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$191.25 |
| 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 |
$116.88
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$102.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.54
|
| Rate for Payer: Blue Distinction Transplant |
$127.50
|
| Rate for Payer: Blue Shield of California Commercial |
$133.66
|
| Rate for Payer: Blue Shield of California EPN |
$103.91
|
| Rate for Payer: Cash Price |
$95.63
|
| 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 Media |
$180.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$159.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$74.38
|
| 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: 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
|
| 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 Medi-Cal |
$180.62
|
| Rate for Payer: Vantage Medical Group Senior |
$180.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
|
IP
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
1796131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Blue Shield of California Commercial |
$159.38
|
| Rate for Payer: Blue Shield of California EPN |
$113.48
|
| Rate for Payer: Cash Price |
$95.63
|
| Rate for Payer: Central Health Plan Commercial |
$170.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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 |
1796131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$191.09 |
| 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 |
$116.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$102.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.44
|
| Rate for Payer: Blue Distinction Transplant |
$127.39
|
| Rate for Payer: Blue Shield of California Commercial |
$133.55
|
| Rate for Payer: Blue Shield of California EPN |
$103.82
|
| Rate for Payer: Cash Price |
$95.54
|
| 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 Media |
$180.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$159.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$74.31
|
| 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: 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
|
| 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 Medi-Cal |
$180.47
|
| Rate for Payer: Vantage Medical Group Senior |
$180.47
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]
|
Facility
|
IP
|
$50.24
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
1743565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$45.22 |
| Rate for Payer: Blue Shield of California Commercial |
$37.68
|
| Rate for Payer: Blue Shield of California EPN |
$26.83
|
| Rate for Payer: Cash Price |
$22.61
|
| Rate for Payer: Central Health Plan Commercial |
$40.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.10
|
| Rate for Payer: Galaxy Health WC |
$42.70
|
| Rate for Payer: Global Benefits Group Commercial |
$30.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$45.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.05
|
| Rate for Payer: Multiplan Commercial |
$37.68
|
| Rate for Payer: Networks By Design Commercial |
$32.66
|
| Rate for Payer: Prime Health Services Commercial |
$42.70
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]
|
Facility
|
OP
|
$50.24
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
1743565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$45.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.68
|
| Rate for Payer: Blue Distinction Transplant |
$30.14
|
| Rate for Payer: Blue Shield of California Commercial |
$31.60
|
| Rate for Payer: Blue Shield of California EPN |
$24.57
|
| Rate for Payer: Cash Price |
$22.61
|
| Rate for Payer: Central Health Plan Commercial |
$40.19
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$37.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.70
|
| Rate for Payer: Dignity Health Media |
$42.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.10
|
| Rate for Payer: Galaxy Health WC |
$42.70
|
| Rate for Payer: Global Benefits Group Commercial |
$30.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$45.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$37.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$17.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.05
|
| Rate for Payer: Multiplan Commercial |
$37.68
|
| Rate for Payer: Networks By Design Commercial |
$32.66
|
| Rate for Payer: Prime Health Services Commercial |
$42.70
|
| Rate for Payer: Riverside University Health System MISP |
$20.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.12
|
| Rate for Payer: United Healthcare All Other HMO |
$25.12
|
| Rate for Payer: United Healthcare HMO Rider |
$25.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$25.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.70
|
| Rate for Payer: Vantage Medical Group Senior |
$42.70
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]
|
Facility
|
IP
|
$96.33
|
|
|
Service Code
|
NDC 0009-0349-03
|
| Hospital Charge Code |
ERX28026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.27 |
| Max. Negotiated Rate |
$86.70 |
| Rate for Payer: Blue Shield of California Commercial |
$72.25
|
| Rate for Payer: Blue Shield of California EPN |
$51.44
|
| Rate for Payer: Cash Price |
$43.35
|
| Rate for Payer: Central Health Plan Commercial |
$77.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.53
|
| Rate for Payer: Galaxy Health WC |
$81.88
|
| Rate for Payer: Global Benefits Group Commercial |
$57.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.27
|
| Rate for Payer: Multiplan Commercial |
$72.25
|
| Rate for Payer: Networks By Design Commercial |
$62.61
|
| Rate for Payer: Prime Health Services Commercial |
$81.88
|
|
