|
HIV WITH MAJOR HIV RELATED CONDITION
|
Facility
|
IP
|
$10,807.47
|
|
|
Service Code
|
APR-DRG 8921
|
| Min. Negotiated Rate |
$8,290.46 |
| Max. Negotiated Rate |
$10,807.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,290.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,807.47
|
|
|
HIV WITH MAJOR HIV RELATED CONDITION
|
Facility
|
IP
|
$15,906.15
|
|
|
Service Code
|
APR-DRG 8923
|
| Min. Negotiated Rate |
$12,201.69 |
| Max. Negotiated Rate |
$15,906.15 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,201.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,906.15
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$12,885.95
|
|
|
Service Code
|
APR-DRG 8901
|
| Min. Negotiated Rate |
$9,884.88 |
| Max. Negotiated Rate |
$12,885.95 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,884.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,885.95
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$20,236.96
|
|
|
Service Code
|
APR-DRG 8903
|
| Min. Negotiated Rate |
$15,523.88 |
| Max. Negotiated Rate |
$20,236.96 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,523.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,236.96
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$38,668.52
|
|
|
Service Code
|
APR-DRG 8904
|
| Min. Negotiated Rate |
$29,662.82 |
| Max. Negotiated Rate |
$38,668.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29,662.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38,668.52
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$13,565.20
|
|
|
Service Code
|
APR-DRG 8902
|
| Min. Negotiated Rate |
$10,405.94 |
| Max. Negotiated Rate |
$13,565.20 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,405.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,565.20
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$27,477.99
|
|
|
Service Code
|
APR-DRG 8934
|
| Min. Negotiated Rate |
$21,078.51 |
| Max. Negotiated Rate |
$27,477.99 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,078.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27,477.99
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$11,905.23
|
|
|
Service Code
|
APR-DRG 8931
|
| Min. Negotiated Rate |
$9,132.56 |
| Max. Negotiated Rate |
$11,905.23 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,132.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,905.23
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$18,000.62
|
|
|
Service Code
|
APR-DRG 8933
|
| Min. Negotiated Rate |
$13,808.37 |
| Max. Negotiated Rate |
$18,000.62 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,808.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,000.62
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$12,894.82
|
|
|
Service Code
|
APR-DRG 8932
|
| Min. Negotiated Rate |
$9,891.69 |
| Max. Negotiated Rate |
$12,894.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,891.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,894.82
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$15,891.98
|
|
|
Service Code
|
APR-DRG 8943
|
| Min. Negotiated Rate |
$12,190.82 |
| Max. Negotiated Rate |
$15,891.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,190.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,891.98
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$10,984.81
|
|
|
Service Code
|
APR-DRG 8942
|
| Min. Negotiated Rate |
$8,426.51 |
| Max. Negotiated Rate |
$10,984.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,426.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,984.81
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$8,776.86
|
|
|
Service Code
|
APR-DRG 8941
|
| Min. Negotiated Rate |
$6,732.78 |
| Max. Negotiated Rate |
$8,776.86 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,732.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,776.86
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$24,560.65
|
|
|
Service Code
|
APR-DRG 8944
|
| Min. Negotiated Rate |
$18,840.61 |
| Max. Negotiated Rate |
$24,560.65 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,840.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,560.65
|
|
|
HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]
|
Facility
|
IP
|
$643.26
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
NDG208396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.38 |
| Max. Negotiated Rate |
$546.77 |
| Rate for Payer: Blue Shield of California Commercial |
$458.00
|
| Rate for Payer: Blue Shield of California EPN |
$329.35
|
| Rate for Payer: Cash Price |
$289.47
|
| Rate for Payer: Cigna of CA HMO |
$450.28
|
| Rate for Payer: Cigna of CA PPO |
$450.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$257.30
|
| Rate for Payer: Galaxy Health WC |
$546.77
|
| Rate for Payer: Global Benefits Group Commercial |
$385.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$429.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$245.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.38
|
| Rate for Payer: Multiplan Commercial |
$514.61
|
| Rate for Payer: Networks By Design Commercial |
$321.63
|
| Rate for Payer: Prime Health Services Commercial |
$546.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$242.89
|
| Rate for Payer: United Healthcare All Other HMO |
$237.23
|
| Rate for Payer: United Healthcare HMO Rider |
$232.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$212.28
|
|
|
HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]
|
Facility
|
OP
|
$643.26
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
NDG208396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.38 |
| Max. Negotiated Rate |
$2,038.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,038.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$546.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$353.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$353.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.26
|
| Rate for Payer: Blue Distinction Transplant |
$385.96
|
| Rate for Payer: Blue Shield of California Commercial |
$474.08
|
| Rate for Payer: Blue Shield of California EPN |
$287.00
|
| Rate for Payer: Cash Price |
$289.47
|
| Rate for Payer: Cash Price |
$289.47
|
| Rate for Payer: Cigna of CA HMO |
$450.28
|
| Rate for Payer: Cigna of CA PPO |
$450.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$546.77
|
| Rate for Payer: Dignity Health Media |
$546.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$546.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$257.30
|
| Rate for Payer: Galaxy Health WC |
$546.77
|
| Rate for Payer: Global Benefits Group Commercial |
$385.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$482.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$429.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.38
|
| Rate for Payer: Multiplan Commercial |
$514.61
|
| Rate for Payer: Networks By Design Commercial |
$321.63
|
| Rate for Payer: Prime Health Services Commercial |
$546.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$385.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$385.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$321.63
|
| Rate for Payer: United Healthcare All Other HMO |
$321.63
|
| Rate for Payer: United Healthcare HMO Rider |
$321.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$321.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$546.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$546.77
|
| Rate for Payer: Vantage Medical Group Senior |
$546.77
|
|
|
HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [206243]
|
Facility
|
IP
|
$3.58
|
|
|
Service Code
|
CPT J7168
|
| Hospital Charge Code |
ERX206243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.83
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.43
|
| Rate for Payer: Galaxy Health WC |
$3.04
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.86
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
|
|
HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [206243]
|
Facility
|
OP
|
$3.58
|
|
|
Service Code
|
CPT J7168
|
| Hospital Charge Code |
ERX206243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$18.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.80
|
| Rate for Payer: Blue Distinction Transplant |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.42
|
| Rate for Payer: Dignity Health Media |
$2.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$3.04
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.74
|
| Rate for Payer: Heritage Provider Network Transplant |
$3.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.05
|
| Rate for Payer: Multiplan Commercial |
$2.86
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.79
|
| Rate for Payer: United Healthcare All Other HMO |
$1.79
|
| Rate for Payer: United Healthcare HMO Rider |
$1.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.28
|
|
|
HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]
|
Facility
|
OP
|
$3.58
|
|
|
Service Code
|
CPT J7168
|
| Hospital Charge Code |
ERX205938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$18.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.80
|
| Rate for Payer: Blue Distinction Transplant |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.42
|
| Rate for Payer: Dignity Health Media |
$2.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$3.04
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.74
|
| Rate for Payer: Heritage Provider Network Transplant |
$3.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.05
|
| Rate for Payer: Multiplan Commercial |
$2.86
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.79
|
| Rate for Payer: United Healthcare All Other HMO |
$1.79
|
| Rate for Payer: United Healthcare HMO Rider |
$1.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.28
|
|
|
HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]
|
Facility
|
IP
|
$3.58
|
|
|
Service Code
|
CPT J7168
|
| Hospital Charge Code |
ERX205938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.83
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.43
|
| Rate for Payer: Galaxy Health WC |
$3.04
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.86
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
|
|
HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]
|
Facility
|
OP
|
$66.96
|
|
|
Service Code
|
CPT J3473
|
| Hospital Charge Code |
1721178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$56.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.97
|
| Rate for Payer: Blue Distinction Transplant |
$40.18
|
| Rate for Payer: Blue Shield of California Commercial |
$49.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cigna of CA HMO |
$46.87
|
| Rate for Payer: Cigna of CA PPO |
$46.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.92
|
| Rate for Payer: Dignity Health Media |
$56.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.78
|
| Rate for Payer: Galaxy Health WC |
$56.92
|
| Rate for Payer: Global Benefits Group Commercial |
$40.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$50.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.07
|
| Rate for Payer: Multiplan Commercial |
$53.57
|
| Rate for Payer: Networks By Design Commercial |
$33.48
|
| Rate for Payer: Prime Health Services Commercial |
$56.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$40.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$40.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.48
|
| Rate for Payer: United Healthcare All Other HMO |
$33.48
|
| Rate for Payer: United Healthcare HMO Rider |
$33.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.92
|
| Rate for Payer: Vantage Medical Group Senior |
$56.92
|
|
|
HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]
|
Facility
|
IP
|
$66.96
|
|
|
Service Code
|
CPT J3473
|
| Hospital Charge Code |
1721178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$56.92 |
| Rate for Payer: Blue Shield of California Commercial |
$47.68
|
| Rate for Payer: Blue Shield of California EPN |
$34.28
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cigna of CA HMO |
$46.87
|
| Rate for Payer: Cigna of CA PPO |
$46.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.78
|
| Rate for Payer: Galaxy Health WC |
$56.92
|
| Rate for Payer: Global Benefits Group Commercial |
$40.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.07
|
| Rate for Payer: Multiplan Commercial |
$53.57
|
| Rate for Payer: Networks By Design Commercial |
$33.48
|
| Rate for Payer: Prime Health Services Commercial |
$56.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.28
|
| Rate for Payer: United Healthcare All Other HMO |
$24.69
|
| Rate for Payer: United Healthcare HMO Rider |
$24.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.10
|
|
|
HYALURONIDASE (OVINE) 200 UNIT/ML INJECTION SOLUTION [40449]
|
Facility
|
IP
|
$120.83
|
|
|
Service Code
|
CPT J3471
|
| Hospital Charge Code |
1721153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.00 |
| Max. Negotiated Rate |
$102.71 |
| Rate for Payer: Blue Shield of California Commercial |
$86.03
|
| Rate for Payer: Blue Shield of California EPN |
$61.86
|
| Rate for Payer: Cash Price |
$54.37
|
| Rate for Payer: Cigna of CA HMO |
$84.58
|
| Rate for Payer: Cigna of CA PPO |
$84.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.33
|
| Rate for Payer: Galaxy Health WC |
$102.71
|
| Rate for Payer: Global Benefits Group Commercial |
$72.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.00
|
| Rate for Payer: Multiplan Commercial |
$96.66
|
| Rate for Payer: Networks By Design Commercial |
$60.42
|
| Rate for Payer: Prime Health Services Commercial |
$102.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.63
|
| Rate for Payer: United Healthcare All Other HMO |
$44.56
|
| Rate for Payer: United Healthcare HMO Rider |
$43.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.87
|
|
|
HYALURONIDASE (OVINE) 200 UNIT/ML INJECTION SOLUTION [40449]
|
Facility
|
OP
|
$120.83
|
|
|
Service Code
|
CPT J3471
|
| Hospital Charge Code |
1721153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$102.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$66.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Distinction Transplant |
$72.50
|
| Rate for Payer: Blue Shield of California Commercial |
$89.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$54.37
|
| Rate for Payer: Cash Price |
$54.37
|
| Rate for Payer: Cigna of CA HMO |
$84.58
|
| Rate for Payer: Cigna of CA PPO |
$84.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.71
|
| Rate for Payer: Dignity Health Media |
$102.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.33
|
| Rate for Payer: Galaxy Health WC |
$102.71
|
| Rate for Payer: Global Benefits Group Commercial |
$72.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$90.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.00
|
| Rate for Payer: Multiplan Commercial |
$96.66
|
| Rate for Payer: Networks By Design Commercial |
$60.42
|
| Rate for Payer: Prime Health Services Commercial |
$102.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.42
|
| Rate for Payer: United Healthcare All Other HMO |
$60.42
|
| Rate for Payer: United Healthcare HMO Rider |
$60.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.71
|
| Rate for Payer: Vantage Medical Group Senior |
$102.71
|
|
|
HYDRALAZINE 10 MG TABLET [3698]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0904-6440-61
|
| Hospital Charge Code |
1711080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
