|
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 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: AlphaCare Medical Group Commercial/Exchange |
$2,075.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,343.09
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$2,075.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,075.68
|
|
|
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 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$77.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$50.23
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$77.62
|
| Rate for Payer: Vantage Medical Group Senior |
$77.62
|
|
|
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 |
$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: AlphaCare Medical Group Commercial/Exchange |
$180.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$116.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$159.24
|
| Rate for Payer: Blue Shield of California Commercial |
$131.85
|
| Rate for Payer: Blue Shield of California EPN |
$124.63
|
| Rate for Payer: Cash Price |
$95.54
|
| 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 |
$102.34
|
| 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
|
| 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
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
1796131
|
|
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: Aetna of CA Non-Gatekeeper |
$145.99
|
| Rate for Payer: Cash Price |
$95.63
|
| 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
|
$212.50
|
|
|
Service Code
|
NDC 85412-863-04
|
| Hospital Charge Code |
1796131
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$180.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$116.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$159.38
|
| Rate for Payer: Blue Shield of California Commercial |
$131.96
|
| Rate for Payer: Blue Shield of California EPN |
$124.74
|
| Rate for Payer: Cash Price |
$95.63
|
| 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 |
$102.42
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.62
|
| Rate for Payer: Vantage Medical Group Senior |
$180.62
|
|
|
GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]
|
Facility
IP
|
$212.32
|
|
|
Service Code
|
NDC 85412-863-09
|
| Hospital Charge Code |
1796131
|
|
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: Aetna of CA Non-Gatekeeper |
$145.86
|
| Rate for Payer: Cash Price |
$95.54
|
| 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
|
$50.24
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
1743565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$37.68 |
| Rate for Payer: Adventist Health Commercial |
$10.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.51
|
| Rate for Payer: Cash Price |
$22.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.01
|
| Rate for Payer: Heritage Provider Network Senior |
$34.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.56
|
| Rate for Payer: Multiplan Commercial |
$37.68
|
|
|
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 |
$9.09 |
| Max. Negotiated Rate |
$42.70 |
| Rate for Payer: Adventist Health Commercial |
$10.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$42.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$27.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.68
|
| Rate for Payer: Blue Shield of California Commercial |
$31.20
|
| Rate for Payer: Blue Shield of California EPN |
$29.49
|
| Rate for Payer: Cash Price |
$22.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.70
|
| Rate for Payer: Dignity Health Senior |
$42.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.10
|
| Rate for Payer: Heritage Provider Network Senior |
$31.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.56
|
| Rate for Payer: Multiplan Commercial |
$37.68
|
| 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
OP
|
$96.33
|
|
|
Service Code
|
NDC 0009-0349-03
|
| Hospital Charge Code |
ERX28026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Adventist Health Commercial |
$19.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$72.25
|
| Rate for Payer: Blue Shield of California Commercial |
$59.82
|
| Rate for Payer: Blue Shield of California EPN |
$56.55
|
| Rate for Payer: Cash Price |
$43.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.88
|
| Rate for Payer: Dignity Health Senior |
$81.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.63
|
| Rate for Payer: Heritage Provider Network Senior |
$59.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.08
|
| Rate for Payer: Multiplan Commercial |
$72.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.88
|
| Rate for Payer: Vantage Medical Group Senior |
$81.88
|
|
|
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 |
$17.44 |
| Max. Negotiated Rate |
$72.25 |
| Rate for Payer: Adventist Health Commercial |
$19.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.18
|
| Rate for Payer: Cash Price |
$43.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.22
|
| Rate for Payer: Heritage Provider Network Senior |
$65.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.08
|
| Rate for Payer: Multiplan Commercial |
$72.25
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]
|
Facility
OP
|
$16.16
|
|
|
Service Code
|
NDC 0009-0396-05
|
| Hospital Charge Code |
ERX28023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$13.74 |
| Rate for Payer: Adventist Health Commercial |
$3.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.12
|
| Rate for Payer: Blue Shield of California Commercial |
$10.04
|
| Rate for Payer: Blue Shield of California EPN |
$9.49
|
| Rate for Payer: Cash Price |
$7.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.74
|
| Rate for Payer: Dignity Health Senior |
$13.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.00
|
| Rate for Payer: Heritage Provider Network Senior |
$10.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.04
|
| Rate for Payer: Multiplan Commercial |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.74
|
| Rate for Payer: Vantage Medical Group Senior |
$13.74
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]
|
Facility
IP
|
$16.16
|
|
|
Service Code
|
NDC 0009-0396-05
|
| Hospital Charge Code |
ERX28023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$12.12 |
| Rate for Payer: Adventist Health Commercial |
$3.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.10
|
| Rate for Payer: Cash Price |
$7.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.94
|
| Rate for Payer: Heritage Provider Network Senior |
$10.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.04
|
| Rate for Payer: Multiplan Commercial |
$12.12
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]
|
Facility
IP
|
$33.61
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
1743564
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$25.21 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.09
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.75
|
| Rate for Payer: Heritage Provider Network Senior |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.21
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]
|
Facility
OP
|
$33.61
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
1743564
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$28.57 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.21
|
| Rate for Payer: Blue Shield of California Commercial |
$20.87
|
| Rate for Payer: Blue Shield of California EPN |
$19.73
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.57
|
| Rate for Payer: Dignity Health Senior |
$28.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.80
|
| Rate for Payer: Heritage Provider Network Senior |
$20.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.57
|
| Rate for Payer: Vantage Medical Group Senior |
$28.57
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
IP
|
$15.84
|
|
|
Service Code
|
CPT J9196
|
| Hospital Charge Code |
NDG220785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Cash Price |
$7.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Senior |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.29
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
IP
|
$6.65
|
|
|
Service Code
|
CPT J9196
|
| Hospital Charge Code |
NDG220785B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.57
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Senior |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.22
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
OP
|
$6.65
|
|
|
Service Code
|
CPT J9196
|
| Hospital Charge Code |
NDG220785B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$21.87 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.66
|
| Rate for Payer: Blue Shield of California Commercial |
$4.13
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.66
|
| Rate for Payer: Dignity Health Senior |
$12.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Senior |
$3.08
|
| Rate for Payer: Humana Medicare |
$11.51
|
| Rate for Payer: IEHP Medi-Cal |
$20.65
|
| Rate for Payer: IEHP Medicare Advantage |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.50
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.66
|
| Rate for Payer: TriValley Medical Group Senior |
$11.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.66
|
| Rate for Payer: Vantage Medical Group Senior |
$11.51
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]
|
Facility
OP
|
$15.84
|
|
|
Service Code
|
CPT J9196
|
| Hospital Charge Code |
NDG220785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$21.87 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.66
|
| Rate for Payer: Blue Shield of California Commercial |
$9.84
|
| Rate for Payer: Blue Shield of California EPN |
$9.30
|
| Rate for Payer: Cash Price |
$7.13
|
| Rate for Payer: Cash Price |
$7.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.66
|
| Rate for Payer: Dignity Health Senior |
$12.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.14
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.33
|
| Rate for Payer: Heritage Provider Network Senior |
$7.33
|
| Rate for Payer: Humana Medicare |
$11.51
|
| Rate for Payer: IEHP Medi-Cal |
$20.65
|
| Rate for Payer: IEHP Medicare Advantage |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.50
|
| Rate for Payer: Multiplan Commercial |
$11.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.66
|
| Rate for Payer: TriValley Medical Group Senior |
$11.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.66
|
| Rate for Payer: Vantage Medical Group Senior |
$11.51
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]
|
Facility
OP
|
$2.07
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
NDG191075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$226.89 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$226.89
|
| Rate for Payer: Blue Shield of California Commercial |
$10.21
|
| Rate for Payer: Blue Shield of California EPN |
$10.21
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.76
|
| Rate for Payer: Dignity Health Senior |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Senior |
$0.96
|
| Rate for Payer: IEHP Medi-Cal |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Vantage Medical Group Senior |
$1.76
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]
|
Facility
IP
|
$2.07
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
NDG191075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.69
|
|
|
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]
|
Facility
OP
|
$55.12
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
1755609
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$226.89 |
| Rate for Payer: Adventist Health Commercial |
$11.02
|
| Rate for Payer: Adventist Health Commercial |
$11.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$46.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$226.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$226.89
|
| Rate for Payer: Blue Shield of California Commercial |
$10.21
|
| Rate for Payer: Blue Shield of California Commercial |
$10.21
|
| Rate for Payer: Blue Shield of California EPN |
$10.21
|
| Rate for Payer: Blue Shield of California EPN |
$10.21
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$46.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: Dignity Health Senior |
$47.94
|
| Rate for Payer: Dignity Health Senior |
$46.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.52
|
| Rate for Payer: Heritage Provider Network Senior |
$26.11
|
| Rate for Payer: Heritage Provider Network Senior |
$25.52
|
| Rate for Payer: IEHP Medi-Cal |
$12.65
|
| Rate for Payer: IEHP Medi-Cal |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.10
|
| Rate for Payer: Multiplan Commercial |
$42.30
|
| Rate for Payer: Multiplan Commercial |
$41.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46.85
|
| Rate for Payer: Vantage Medical Group Senior |
$46.85
|
| Rate for Payer: Vantage Medical Group Senior |
$47.94
|
|
|
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]
|
Facility
IP
|
$56.40
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
1755609
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Adventist Health Commercial |
$11.28
|
| Rate for Payer: Adventist Health Commercial |
$11.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.75
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.32
|
| Rate for Payer: Heritage Provider Network Senior |
$38.18
|
| Rate for Payer: Heritage Provider Network Senior |
$37.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.78
|
| Rate for Payer: Multiplan Commercial |
$42.30
|
| Rate for Payer: Multiplan Commercial |
$41.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.42
|
|
