|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
1711941
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.68
|
| Rate for Payer: Dignity Health Senior |
$4.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Senior |
$3.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4.68
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
1711941
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.78
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$537.12
|
|
|
Service Code
|
CPT J1458
|
| Hospital Charge Code |
1759999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.22 |
| Max. Negotiated Rate |
$1,137.39 |
| Rate for Payer: Adventist Health Commercial |
$107.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,137.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$578.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$509.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$509.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$645.48
|
| Rate for Payer: Blue Shield of California Commercial |
$426.77
|
| Rate for Payer: Blue Shield of California EPN |
$426.77
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$694.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$509.29
|
| Rate for Payer: Dignity Health Senior |
$509.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$462.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$248.69
|
| Rate for Payer: Heritage Provider Network Senior |
$248.69
|
| Rate for Payer: Humana Medicare |
$462.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$729.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$462.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$879.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$546.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$583.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$583.37
|
| Rate for Payer: Multiplan Commercial |
$402.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$214.85
|
| Rate for Payer: TriValley Medical Group Senior |
$214.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$694.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$509.29
|
| Rate for Payer: Vantage Medical Group Senior |
$462.99
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
IP
|
$537.12
|
|
|
Service Code
|
CPT J1458
|
| Hospital Charge Code |
1759999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.22 |
| Max. Negotiated Rate |
$402.84 |
| Rate for Payer: Adventist Health Commercial |
$107.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.00
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$363.63
|
| Rate for Payer: Heritage Provider Network Senior |
$363.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.28
|
| Rate for Payer: Multiplan Commercial |
$402.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.45
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
OP
|
$106.43
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
1740429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$90.47 |
| Rate for Payer: Adventist Health Commercial |
$21.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.82
|
| Rate for Payer: Blue Shield of California Commercial |
$66.09
|
| Rate for Payer: Blue Shield of California EPN |
$62.47
|
| Rate for Payer: Cash Price |
$47.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.47
|
| Rate for Payer: Dignity Health Senior |
$90.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.88
|
| Rate for Payer: Heritage Provider Network Senior |
$65.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.61
|
| Rate for Payer: Multiplan Commercial |
$79.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.57
|
| Rate for Payer: TriValley Medical Group Senior |
$42.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.47
|
| Rate for Payer: Vantage Medical Group Senior |
$90.47
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$106.43
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
1740429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$79.82 |
| Rate for Payer: Adventist Health Commercial |
$21.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.12
|
| Rate for Payer: Cash Price |
$47.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.05
|
| Rate for Payer: Heritage Provider Network Senior |
$72.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.61
|
| Rate for Payer: Multiplan Commercial |
$79.82
|
|
|
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 |
$14.86 |
| Max. Negotiated Rate |
$61.56 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.39
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.57
|
| Rate for Payer: Heritage Provider Network Senior |
$55.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.52
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.42
|
|
|
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 |
$14.86 |
| Max. Negotiated Rate |
$69.77 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.39
|
| 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 |
$61.56
|
| Rate for Payer: Blue Shield of California Commercial |
$50.97
|
| Rate for Payer: Blue Shield of California EPN |
$48.18
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: Dignity Health Senior |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.00
|
| Rate for Payer: Heritage Provider Network Senior |
$38.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.52
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.83
|
| Rate for Payer: TriValley Medical Group Senior |
$32.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.42
|
| 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 |
$14.86 |
| Max. Negotiated Rate |
$61.56 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.39
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.57
|
| Rate for Payer: Heritage Provider Network Senior |
$55.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.52
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.42
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-10
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.86 |
| Max. Negotiated Rate |
$69.77 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.39
|
| 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 |
$61.56
|
| Rate for Payer: Blue Shield of California Commercial |
$50.97
|
| Rate for Payer: Blue Shield of California EPN |
$48.18
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: Dignity Health Senior |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.00
|
| Rate for Payer: Heritage Provider Network Senior |
$38.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.52
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.83
|
| Rate for Payer: TriValley Medical Group Senior |
$32.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$10,113.12
|
|
|
Service Code
|
APR-DRG 2321
|
| Min. Negotiated Rate |
$10,113.12 |
| Max. Negotiated Rate |
$10,113.12 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,113.12
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$16,329.23
|
|
|
Service Code
|
APR-DRG 2323
|
| Min. Negotiated Rate |
$16,329.23 |
| Max. Negotiated Rate |
$16,329.23 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,329.23
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$35,834.16
|
|
|
Service Code
|
APR-DRG 2324
|
| Min. Negotiated Rate |
$35,834.16 |
| Max. Negotiated Rate |
$35,834.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35,834.16
|
|
|
GASTRIC FUNDOPLICATION
|
Facility
|
IP
|
$12,353.62
|
|
|
Service Code
|
APR-DRG 2322
|
| Min. Negotiated Rate |
$12,353.62 |
| Max. Negotiated Rate |
$12,353.62 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,353.62
|
|
|
Gastrocnemius recession (eg, Strayer procedure)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27687
|
| Min. Negotiated Rate |
$512.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$512.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$9,351.03
|
|
|
Service Code
|
APR-DRG 2463
|
| Min. Negotiated Rate |
$9,351.03 |
| Max. Negotiated Rate |
$9,351.03 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,351.03
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$5,227.18
|
|
|
Service Code
|
APR-DRG 2461
|
| Min. Negotiated Rate |
$5,227.18 |
| Max. Negotiated Rate |
$5,227.18 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,227.18
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$6,616.06
|
|
|
Service Code
|
APR-DRG 2462
|
| Min. Negotiated Rate |
$6,616.06 |
| Max. Negotiated Rate |
$6,616.06 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,616.06
|
|
|
GASTROINTESTINAL VASCULAR INSUFFICIENCY
|
Facility
|
IP
|
$13,517.65
|
|
|
Service Code
|
APR-DRG 2464
|
| Min. Negotiated Rate |
$13,517.65 |
| Max. Negotiated Rate |
$13,517.65 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,517.65
|
|
|
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 |
$48.61 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.49
|
| Rate for Payer: Cash Price |
$120.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.80
|
| Rate for Payer: Heritage Provider Network Senior |
$181.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.14
|
| Rate for Payer: Multiplan Commercial |
$201.40
|
|
|
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 |
$48.61 |
| Max. Negotiated Rate |
$228.26 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.49
|
| 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 |
$201.40
|
| Rate for Payer: Blue Shield of California Commercial |
$166.76
|
| Rate for Payer: Blue Shield of California EPN |
$157.63
|
| Rate for Payer: Cash Price |
$120.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.26
|
| Rate for Payer: Dignity Health Senior |
$228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.23
|
| Rate for Payer: Heritage Provider Network Senior |
$166.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$129.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.14
|
| Rate for Payer: Multiplan Commercial |
$201.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.42
|
| Rate for Payer: TriValley Medical Group Senior |
$107.42
|
| 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 |
$442.00 |
| Max. Negotiated Rate |
$1,831.48 |
| Rate for Payer: Adventist Health Commercial |
$488.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,677.64
|
| Rate for Payer: Cash Price |
$1,098.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,318.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,653.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1,653.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$442.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$610.50
|
| Rate for Payer: Multiplan Commercial |
$1,831.48
|
|
|
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 |
$442.00 |
| Max. Negotiated Rate |
$2,075.68 |
| Rate for Payer: Adventist Health Commercial |
$488.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,305.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,677.64
|
| 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 |
$1,831.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1,516.47
|
| Rate for Payer: Blue Shield of California EPN |
$1,433.44
|
| Rate for Payer: Cash Price |
$1,098.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,587.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,075.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,075.68
|
| Rate for Payer: Dignity Health Senior |
$2,075.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,562.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,511.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1,511.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,177.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$442.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$610.50
|
| Rate for Payer: Multiplan Commercial |
$1,831.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$976.79
|
| Rate for Payer: TriValley Medical Group Senior |
$976.79
|
| 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 |
$16.53 |
| Max. Negotiated Rate |
$77.62 |
| Rate for Payer: Adventist Health Commercial |
$18.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$62.74
|
| 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 |
$68.49
|
| Rate for Payer: Blue Shield of California Commercial |
$56.71
|
| Rate for Payer: Blue Shield of California EPN |
$53.60
|
| Rate for Payer: Cash Price |
$41.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$77.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$77.62
|
| Rate for Payer: Dignity Health Senior |
$77.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.53
|
| Rate for Payer: Heritage Provider Network Senior |
$56.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$44.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.83
|
| Rate for Payer: Multiplan Commercial |
$68.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.53
|
| Rate for Payer: TriValley Medical Group Senior |
$36.53
|
| 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 |
$16.53 |
| Max. Negotiated Rate |
$68.49 |
| Rate for Payer: Adventist Health Commercial |
$18.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$62.74
|
| Rate for Payer: Cash Price |
$41.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.82
|
| Rate for Payer: Heritage Provider Network Senior |
$61.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.83
|
| Rate for Payer: Multiplan Commercial |
$68.49
|
|
