|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Cigna of CA HMO/PPO |
$4.24
|
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: Blue Shield of California Commercial |
$3.98
|
| Rate for Payer: Blue Shield of California EPN |
$3.18
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Senior |
$4.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.56
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Senior |
$2.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.54
|
| Rate for Payer: Vantage Medical Group Senior |
$5.54
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.20
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.41
|
| Rate for Payer: Heritage Provider Network Senior |
$4.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
OP
|
$17.04
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$31.51 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$31.51
|
| Rate for Payer: Blue Shield of California Commercial |
$10.39
|
| Rate for Payer: Blue Shield of California EPN |
$8.32
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.55
|
| Rate for Payer: Heritage Provider Network Senior |
$10.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.82
|
| Rate for Payer: TriValley Medical Group Senior |
$6.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.48
|
| Rate for Payer: Vantage Medical Group Senior |
$14.48
|
|
|
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: Aetna of CA Non-Gatekeeper |
$10.97
|
| Rate for Payer: Cash Price |
$7.67
|
| 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 Foundation Hospitals 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
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378810693
|
| 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 Non-Gatekeeper |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.75
|
| 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 |
$2.48
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378810693
|
| 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: Aetna of CA Non-Gatekeeper |
$3.54
|
| 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 Foundation Hospitals 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
|
IP
|
$611.76
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.73 |
| Max. Negotiated Rate |
$458.82 |
| Rate for Payer: Adventist Health Commercial |
$122.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$393.97
|
| Rate for Payer: Cash Price |
$275.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$281.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$330.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.24
|
| Rate for Payer: Heritage Provider Network Senior |
$283.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$110.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.94
|
| Rate for Payer: Multiplan Commercial |
$458.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$202.55
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$611.76
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.73 |
| Max. Negotiated Rate |
$788.96 |
| Rate for Payer: Adventist Health Commercial |
$122.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$378.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$788.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$578.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$525.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$732.19
|
| 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 |
$275.29
|
| Rate for Payer: Cash Price |
$275.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$281.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$788.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$578.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$525.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$391.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$525.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.24
|
| Rate for Payer: Heritage Provider Network Senior |
$283.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$525.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$291.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$110.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$604.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$704.80
|
| Rate for Payer: Multiplan Commercial |
$458.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$244.70
|
| Rate for Payer: TriValley Medical Group Senior |
$244.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$202.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$788.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$578.57
|
| Rate for Payer: Vantage Medical Group Senior |
$525.97
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$114.51
|
|
|
Service Code
|
NDC 2420853535
|
| 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: Aetna of CA Non-Gatekeeper |
$73.74
|
| Rate for Payer: Cash Price |
$51.53
|
| 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 Foundation Hospitals 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 2420853535
|
| 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 Non-Gatekeeper |
$70.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.28
|
| 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 |
$51.53
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$54.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
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: Aetna of CA Non-Gatekeeper |
$75.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$52.86
|
| Rate for Payer: Cash Price |
$52.52
|
| Rate for Payer: Cash Price |
$36.94
|
| 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 |
$44.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.00
|
| Rate for Payer: Heritage Provider Network Senior |
$38.00
|
| Rate for Payer: Heritage Provider Network Senior |
$54.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.86
|
| 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: Multiplan Commercial |
$87.54
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| 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+ |
$27.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.65
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$116.72
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.13 |
| Max. Negotiated Rate |
$99.21 |
| Rate for Payer: Adventist Health Commercial |
$23.34
|
| Rate for Payer: Adventist Health Commercial |
$16.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.21
|
| 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 Medi-Cal |
$64.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$87.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.25
|
| 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 |
$52.52
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Cash Price |
$52.52
|
| Rate for Payer: Cash Price |
$36.94
|
| 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 |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$74.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.53
|
| 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 |
$38.00
|
| Rate for Payer: Heritage Provider Network Senior |
$54.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$55.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$39.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.13
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$57.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$81.70
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Multiplan Commercial |
$87.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$46.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.83
|
| 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 |
$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
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$99.21
|
|
|
GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 27687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH CC
|
Facility
|
IP
|
$15,760.70
|
|
|
Service Code
|
MSDRG 378
|
| Min. Negotiated Rate |
$11,761.72 |
| Max. Negotiated Rate |
$15,760.70 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,761.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,761.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,525.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,760.70
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$28,771.38
|
|
|
Service Code
|
MSDRG 377
|
| Min. Negotiated Rate |
$21,471.18 |
| Max. Negotiated Rate |
$28,771.38 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,471.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,471.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,691.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,771.38
|
|
|
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC
|
Facility
|
IP
|
$10,381.69
|
|
|
Service Code
|
MSDRG 379
|
| Min. Negotiated Rate |
$7,747.53 |
| Max. Negotiated Rate |
$10,381.69 |
| Rate for Payer: EPIC Health Plan Medicare |
$7,747.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,747.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,909.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,381.69
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH CC
|
Facility
|
IP
|
$12,829.36
|
|
|
Service Code
|
MSDRG 389
|
| Min. Negotiated Rate |
$9,574.15 |
| Max. Negotiated Rate |
$12,829.36 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,574.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,574.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,010.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,829.36
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH MCC
|
Facility
|
IP
|
$23,378.56
|
|
|
Service Code
|
MSDRG 388
|
| Min. Negotiated Rate |
$17,446.69 |
| Max. Negotiated Rate |
$23,378.56 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,446.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,446.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,063.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,378.56
|
|
|
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC
|
Facility
|
IP
|
$9,054.97
|
|
|
Service Code
|
MSDRG 390
|
| Min. Negotiated Rate |
$6,757.44 |
| Max. Negotiated Rate |
$9,054.97 |
| Rate for Payer: EPIC Health Plan Medicare |
$6,757.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,757.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7,771.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9,054.97
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
IP
|
$268.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.61 |
| Max. Negotiated Rate |
$201.41 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$172.94
|
| Rate for Payer: Cash Price |
$120.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$123.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$124.33
|
| Rate for Payer: Heritage Provider Network Senior |
$124.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.14
|
| Rate for Payer: Multiplan Commercial |
$201.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$97.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.91
|
|
|
GELATIN ABSORBABLE EYE FILM [28028]
|
Facility
|
OP
|
$268.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.61 |
| Max. Negotiated Rate |
$228.26 |
| Rate for Payer: Adventist Health Commercial |
$53.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$165.96
|
| 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 |
$120.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$123.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$124.33
|
| Rate for Payer: Heritage Provider Network Senior |
$124.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$128.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$97.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.91
|
| 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 IMPLANT FILM [111340]
|
Facility
|
OP
|
$2,692.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$487.30 |
| Max. Negotiated Rate |
$2,288.44 |
| Rate for Payer: Adventist Health Commercial |
$538.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,663.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,288.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,480.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,019.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1,642.29
|
| Rate for Payer: Blue Shield of California EPN |
$1,313.83
|
| Rate for Payer: Cash Price |
$1,211.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,238.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,288.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,288.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,288.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,723.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,246.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1,246.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,284.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$487.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$673.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,884.60
|
| Rate for Payer: Multiplan Commercial |
$2,019.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,076.91
|
| Rate for Payer: TriValley Medical Group Senior |
$1,076.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$972.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$891.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,288.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,288.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2,288.44
|
|
|
GELATIN ABSORBABLE IMPLANT FILM [111340]
|
Facility
|
IP
|
$2,692.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$487.30 |
| Max. Negotiated Rate |
$2,019.21 |
| Rate for Payer: Adventist Health Commercial |
$538.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,733.83
|
| Rate for Payer: Cash Price |
$1,211.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,238.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,453.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,246.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1,246.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$487.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$673.07
|
| Rate for Payer: Multiplan Commercial |
$2,019.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$972.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$891.41
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
OP
|
$100.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.22 |
| Max. Negotiated Rate |
$85.58 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$62.22
|
| 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 |
$45.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.61
|
| Rate for Payer: Heritage Provider Network Senior |
$46.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$48.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$36.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.34
|
| 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 ABSORBABLE MUCOSAL POWDER [28017]
|
Facility
|
IP
|
$100.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.22 |
| Max. Negotiated Rate |
$75.51 |
| Rate for Payer: Adventist Health Commercial |
$20.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$64.84
|
| Rate for Payer: Cash Price |
$45.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.61
|
| Rate for Payer: Heritage Provider Network Senior |
$46.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Multiplan Commercial |
$75.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.34
|
|
