|
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 |
$3.08 |
| Max. Negotiated Rate |
$12.78 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.54
|
| Rate for Payer: Heritage Provider Network Senior |
$11.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.26
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
|
|
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 |
$1.00 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$3.02
|
| 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
|
|
|
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 |
$1.00 |
| Max. Negotiated Rate |
$4.67 |
| 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 |
$4.67
|
| 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: Blue Shield of California Commercial |
$3.35
|
| Rate for Payer: Blue Shield of California EPN |
$2.68
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.67
|
| Rate for Payer: Dignity Health Senior |
$4.67
|
| 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 |
$2.62
|
| 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: 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: TriValley Medical Group Commercial |
$2.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$108.04 |
| Max. Negotiated Rate |
$447.66 |
| Rate for Payer: Adventist Health Commercial |
$119.38
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$274.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$322.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.36
|
| Rate for Payer: Heritage Provider Network Senior |
$276.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.22
|
| Rate for Payer: Multiplan Commercial |
$447.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$215.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$197.63
|
|
|
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 |
$108.04 |
| Max. Negotiated Rate |
$1,269.60 |
| Rate for Payer: Adventist Health Commercial |
$119.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$319.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$410.06
|
| 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 HMO/PPO |
$1,269.60
|
| Rate for Payer: Blue Shield of California Commercial |
$478.58
|
| Rate for Payer: Blue Shield of California EPN |
$478.58
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$274.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$507.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$507.35
|
| Rate for Payer: Dignity Health Senior |
$507.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$382.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.36
|
| Rate for Payer: Heritage Provider Network Senior |
$276.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$484.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$284.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.22
|
| 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: TriValley Medical Group Commercial |
$238.75
|
| Rate for Payer: TriValley Medical Group Senior |
$238.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$215.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$197.63
|
| 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 |
$20.73 |
| Max. Negotiated Rate |
$85.88 |
| Rate for Payer: Adventist Health Commercial |
$22.90
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.52
|
| Rate for Payer: Heritage Provider Network Senior |
$77.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.63
|
| Rate for Payer: Multiplan Commercial |
$85.88
|
|
|
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 |
$20.73 |
| Max. Negotiated Rate |
$97.33 |
| Rate for Payer: Adventist Health Commercial |
$22.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.67
|
| 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: Blue Shield of California Commercial |
$69.85
|
| Rate for Payer: Blue Shield of California EPN |
$55.88
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.33
|
| Rate for Payer: Dignity Health Senior |
$97.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.88
|
| Rate for Payer: Heritage Provider Network Senior |
$70.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$54.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.63
|
| 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: TriValley Medical Group Commercial |
$45.80
|
| Rate for Payer: TriValley Medical Group Senior |
$45.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$14.86 |
| Max. Negotiated Rate |
$180.09 |
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.19
|
| 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 HMO/PPO |
$180.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$180.09
|
| Rate for Payer: Blue Shield of California Commercial |
$73.44
|
| Rate for Payer: Blue Shield of California Commercial |
$73.44
|
| Rate for Payer: Blue Shield of California EPN |
$73.44
|
| Rate for Payer: Blue Shield of California EPN |
$73.44
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: Dignity Health Senior |
$99.21
|
| Rate for Payer: Dignity Health Senior |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$74.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.04
|
| Rate for Payer: Heritage Provider Network Senior |
$54.04
|
| Rate for Payer: Heritage Provider Network Senior |
$38.00
|
| 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: Kaiser Permanente of CA Commercial |
$39.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$81.70
|
| 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 |
$61.56
|
| Rate for Payer: Multiplan Commercial |
$87.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$46.69
|
| Rate for Payer: TriValley Medical Group Senior |
$46.69
|
| Rate for Payer: TriValley Medical Group Senior |
$32.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.18
|
| 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 |
$99.21
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$116.72
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.13 |
| Max. Negotiated Rate |
$87.54 |
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.04
|
| Rate for Payer: Heritage Provider Network Senior |
$54.04
|
| Rate for Payer: Heritage Provider Network Senior |
$38.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.13
|
| 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: LLUH Dept of Risk Management WC |
$29.18
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Multiplan Commercial |
$87.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.65
|
|
|
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 |
$48.61 |
| Max. Negotiated Rate |
$201.41 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Cash Price |
$147.69
|
| 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 |
$201.41
|
|
|
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 |
$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 |
$201.41
|
| Rate for Payer: Blue Shield of California Commercial |
$163.81
|
| Rate for Payer: Blue Shield of California EPN |
$131.05
|
| Rate for Payer: Cash Price |
$147.69
|
| 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 |
$128.09
|
| 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: 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: TriValley Medical Group Commercial |
$107.42
|
| Rate for Payer: TriValley Medical Group Senior |
$107.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$18.22 |
| Max. Negotiated Rate |
$75.51 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Cash Price |
$55.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.16
|
| Rate for Payer: Heritage Provider Network Senior |
$68.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Multiplan Commercial |
$75.51
|
|
|
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 |
$18.22 |
| Max. Negotiated Rate |
$85.58 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.17
|
| 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: Blue Shield of California Commercial |
$61.41
|
| Rate for Payer: Blue Shield of California EPN |
$49.13
|
| Rate for Payer: Cash Price |
$55.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.58
|
| Rate for Payer: Dignity Health Senior |
$85.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.32
|
| Rate for Payer: Heritage Provider Network Senior |
$62.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| 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: TriValley Medical Group Commercial |
$40.27
|
| Rate for Payer: TriValley Medical Group Senior |
$40.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$50.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$38.46 |
| Max. Negotiated Rate |
$180.62 |
| Rate for Payer: Adventist Health Commercial |
$42.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$113.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.99
|
| 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: Blue Shield of California Commercial |
$129.62
|
| Rate for Payer: Blue Shield of California EPN |
$103.70
|
| Rate for Payer: Cash Price |
$116.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.62
|
| Rate for Payer: Dignity Health Senior |
$180.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.54
|
| Rate for Payer: Heritage Provider Network Senior |
$131.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$101.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.12
|
| 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: TriValley Medical Group Commercial |
$85.00
|
| Rate for Payer: TriValley Medical Group Senior |
$85.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$106.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.46 |
| Max. Negotiated Rate |
$159.38 |
| Rate for Payer: Adventist Health Commercial |
$42.50
|
| Rate for Payer: Cash Price |
$116.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.86
|
| Rate for Payer: Heritage Provider Network Senior |
$143.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.12
|
| Rate for Payer: Multiplan Commercial |
$159.38
|
|
|
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 |
$38.43 |
| Max. Negotiated Rate |
$180.47 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$113.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.86
|
| 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: Blue Shield of California Commercial |
$129.52
|
| Rate for Payer: Blue Shield of California EPN |
$103.61
|
| Rate for Payer: Cash Price |
$116.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.47
|
| Rate for Payer: Dignity Health Senior |
$180.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.43
|
| Rate for Payer: Heritage Provider Network Senior |
$131.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$101.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.08
|
| 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: TriValley Medical Group Commercial |
$84.93
|
| Rate for Payer: TriValley Medical Group Senior |
$84.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$106.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$38.43 |
| Max. Negotiated Rate |
$159.24 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Cash Price |
$116.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.74
|
| Rate for Payer: Heritage Provider Network Senior |
$143.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.08
|
| Rate for Payer: Multiplan Commercial |
$159.24
|
|
|
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 |
$10.03 |
| Max. Negotiated Rate |
$41.54 |
| Rate for Payer: Adventist Health Commercial |
$11.08
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.50
|
| Rate for Payer: Heritage Provider Network Senior |
$37.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.85
|
| Rate for Payer: Multiplan Commercial |
$41.54
|
|
|
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 |
$10.03 |
| Max. Negotiated Rate |
$47.08 |
| Rate for Payer: Adventist Health Commercial |
$11.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$29.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.05
|
| 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: Blue Shield of California Commercial |
$33.79
|
| Rate for Payer: Blue Shield of California EPN |
$27.03
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.08
|
| Rate for Payer: Dignity Health Senior |
$47.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.29
|
| Rate for Payer: Heritage Provider Network Senior |
$34.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.85
|
| 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: TriValley Medical Group Commercial |
$22.16
|
| Rate for Payer: TriValley Medical Group Senior |
$22.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$106.20
|
|
|
Service Code
|
NDC 0009-0349-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.22 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.65
|
| Rate for Payer: Blue Shield of California Commercial |
$64.78
|
| Rate for Payer: Blue Shield of California EPN |
$51.83
|
| Rate for Payer: Cash Price |
$58.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.27
|
| Rate for Payer: Dignity Health Senior |
$90.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.74
|
| Rate for Payer: Heritage Provider Network Senior |
$65.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.34
|
| Rate for Payer: Multiplan Commercial |
$79.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.48
|
| Rate for Payer: TriValley Medical Group Senior |
$42.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$53.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$53.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.27
|
| Rate for Payer: Vantage Medical Group Senior |
$90.27
|
|
|
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 |
$19.22 |
| Max. Negotiated Rate |
$79.65 |
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Cash Price |
$58.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.90
|
| Rate for Payer: Heritage Provider Network Senior |
$71.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.55
|
| Rate for Payer: Multiplan Commercial |
$79.65
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]
|
Facility
|
IP
|
$17.82
|
|
|
Service Code
|
NDC 0009-0396-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$13.37 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Cash Price |
$9.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.06
|
| Rate for Payer: Heritage Provider Network Senior |
$12.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Multiplan Commercial |
$13.37
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]
|
Facility
|
OP
|
$17.82
|
|
|
Service Code
|
NDC 0009-0396-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.37
|
| Rate for Payer: Blue Shield of California Commercial |
$10.87
|
| Rate for Payer: Blue Shield of California EPN |
$8.70
|
| Rate for Payer: Cash Price |
$9.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.15
|
| Rate for Payer: Dignity Health Senior |
$15.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.03
|
| Rate for Payer: Heritage Provider Network Senior |
$11.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.47
|
| Rate for Payer: Multiplan Commercial |
$13.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.13
|
| Rate for Payer: TriValley Medical Group Senior |
$7.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.15
|
| Rate for Payer: Vantage Medical Group Senior |
$15.15
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]
|
Facility
|
OP
|
$37.05
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$31.49 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.79
|
| Rate for Payer: Blue Shield of California Commercial |
$22.60
|
| Rate for Payer: Blue Shield of California EPN |
$18.08
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.49
|
| Rate for Payer: Dignity Health Senior |
$31.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.93
|
| Rate for Payer: Heritage Provider Network Senior |
$22.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.93
|
| Rate for Payer: Multiplan Commercial |
$27.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.82
|
| Rate for Payer: TriValley Medical Group Senior |
$14.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.49
|
| Rate for Payer: Vantage Medical Group Senior |
$31.49
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]
|
Facility
|
IP
|
$37.05
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$27.79 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.08
|
| Rate for Payer: Heritage Provider Network Senior |
$25.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$27.79
|
|
