|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
OP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$387.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$659.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$182.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$341.94
|
| Rate for Payer: Blue Shield of California Commercial |
$163.20
|
| Rate for Payer: Blue Shield of California EPN |
$163.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$441.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$207.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.82
|
| Rate for Payer: Dignity Health Senior |
$182.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$614.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$166.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$444.48
|
| Rate for Payer: Heritage Provider Network Senior |
$444.48
|
| Rate for Payer: Humana Medicare |
$166.20
|
| Rate for Payer: IEHP Medi-Cal |
$256.56
|
| Rate for Payer: IEHP Medicare Advantage |
$166.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$315.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$196.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$209.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$209.41
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$182.82
|
| Rate for Payer: TriValley Medical Group Senior |
$166.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$350.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$320.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: Vantage Medical Group Senior |
$182.82
|
|
|
Goniotomy
|
Facility
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 65820
|
| Min. Negotiated Rate |
$131.84 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: IEHP Medi-Cal |
$131.84
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
IP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.44 |
| Max. Negotiated Rate |
$2,173.10 |
| Rate for Payer: Adventist Health Commercial |
$579.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,990.56
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,332.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,564.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,961.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1,961.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$524.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$724.37
|
| Rate for Payer: Multiplan Commercial |
$2,173.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,056.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$968.04
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
OP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.44 |
| Max. Negotiated Rate |
$2,173.10 |
| Rate for Payer: Adventist Health Commercial |
$579.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,199.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,990.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$930.13
|
| Rate for Payer: Blue Shield of California Commercial |
$773.14
|
| Rate for Payer: Blue Shield of California EPN |
$773.14
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,332.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: Dignity Health Senior |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,854.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$609.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,341.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1,341.53
|
| Rate for Payer: Humana Medicare |
$609.01
|
| Rate for Payer: IEHP Medi-Cal |
$950.06
|
| Rate for Payer: IEHP Medicare Advantage |
$609.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$524.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$718.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$724.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$767.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$767.35
|
| Rate for Payer: Multiplan Commercial |
$2,173.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$669.91
|
| Rate for Payer: TriValley Medical Group Senior |
$609.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,056.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$968.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
OP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.05 |
| Max. Negotiated Rate |
$1,199.44 |
| Rate for Payer: Adventist Health Commercial |
$206.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,199.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$709.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$930.13
|
| Rate for Payer: Blue Shield of California Commercial |
$773.14
|
| Rate for Payer: Blue Shield of California EPN |
$773.14
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$475.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: Dignity Health Senior |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$661.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$609.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$478.48
|
| Rate for Payer: Heritage Provider Network Senior |
$478.48
|
| Rate for Payer: Humana Medicare |
$609.01
|
| Rate for Payer: IEHP Medi-Cal |
$950.06
|
| Rate for Payer: IEHP Medicare Advantage |
$609.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$187.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$718.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$258.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$767.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$767.35
|
| Rate for Payer: Multiplan Commercial |
$775.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$669.91
|
| Rate for Payer: TriValley Medical Group Senior |
$609.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$376.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$345.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
IP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.05 |
| Max. Negotiated Rate |
$775.07 |
| Rate for Payer: Adventist Health Commercial |
$206.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$709.97
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$475.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$558.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$699.63
|
| Rate for Payer: Heritage Provider Network Senior |
$699.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$187.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$258.36
|
| Rate for Payer: Multiplan Commercial |
$775.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$376.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$345.27
|
|
|
Graft, bone; mandible (includes obtaining graft)
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21215
|
| Min. Negotiated Rate |
$232.32 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$232.32
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15760
|
| Min. Negotiated Rate |
$658.04 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$658.04
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Graft; derma-fat-fascia
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15770
|
| Min. Negotiated Rate |
$696.95 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: IEHP Medi-Cal |
$696.95
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21235
|
| Min. Negotiated Rate |
$157.98 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$157.98
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15840
|
| Min. Negotiated Rate |
$1,742.36 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: IEHP Medi-Cal |
$1,742.36
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15773
|
| Min. Negotiated Rate |
$809.17 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$809.17
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15774
|
| Min. Negotiated Rate |
$242.22 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$242.22
|
|
|
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15771
|
| Min. Negotiated Rate |
$801.86 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: IEHP Medi-Cal |
$801.86
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15772
|
| Min. Negotiated Rate |
$249.41 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$249.41
|
|
|
Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15769
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: IEHP Medi-Cal |
$132.41
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21230
|
| Min. Negotiated Rate |
$1,045.42 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$1,045.42
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]
|
Facility
IP
|
$10.80
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
NDG12552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Adventist Health Commercial |
$4.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.55
|
| Rate for Payer: Cash Price |
$10.19
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.31
|
| Rate for Payer: Heritage Provider Network Senior |
$15.33
|
| Rate for Payer: Heritage Provider Network Senior |
$7.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$16.98
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.61
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]
|
Facility
OP
|
$22.64
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
NDG12552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$36.85 |
| Rate for Payer: Adventist Health Commercial |
$4.53
|
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$10.19
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$10.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.18
|
| Rate for Payer: Dignity Health Senior |
$19.24
|
| Rate for Payer: Dignity Health Senior |
$9.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$10.48
|
| Rate for Payer: IEHP Medi-Cal |
$7.55
|
| Rate for Payer: IEHP Medi-Cal |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: Multiplan Commercial |
$16.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.24
|
| Rate for Payer: Vantage Medical Group Senior |
$9.18
|
| Rate for Payer: Vantage Medical Group Senior |
$19.24
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]
|
Facility
IP
|
$10.80
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
NDG92107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.31
|
| Rate for Payer: Heritage Provider Network Senior |
$7.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.61
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]
|
Facility
OP
|
$10.80
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
NDG92107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$36.85 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.18
|
| Rate for Payer: Dignity Health Senior |
$9.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.00
|
| Rate for Payer: IEHP Medi-Cal |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.18
|
| Rate for Payer: Vantage Medical Group Senior |
$9.18
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
OP
|
$4.32
|
|
|
Service Code
|
NDC 51991-735-99
|
| Hospital Charge Code |
1712186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.54
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: Dignity Health Senior |
$3.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
IP
|
$4.32
|
|
|
Service Code
|
NDC 51991-735-99
|
| Hospital Charge Code |
1712186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
OP
|
$4.32
|
|
|
Service Code
|
NDC 51991-735-20
|
| Hospital Charge Code |
1712186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.54
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: Dignity Health Senior |
$3.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
IP
|
$4.32
|
|
|
Service Code
|
NDC 51991-735-20
|
| Hospital Charge Code |
1712186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
|
