|
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS
|
Facility
IP
|
$7,849.34
|
|
|
Service Code
|
APR-DRG 2791
|
| Min. Negotiated Rate |
$6,021.27 |
| Max. Negotiated Rate |
$7,849.34 |
| Rate for Payer: IEHP Medi-Cal |
$6,021.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,849.34
|
|
|
HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE [118915]
|
Facility
OP
|
$143.88
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
NDG118915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.53 |
| Max. Negotiated Rate |
$859.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$859.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$122.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$79.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$79.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.70
|
| Rate for Payer: BCBS Transplant Transplant |
$86.33
|
| Rate for Payer: Blue Shield of California Commercial |
$106.04
|
| Rate for Payer: Blue Shield of California EPN |
$130.65
|
| Rate for Payer: Cash Price |
$64.75
|
| Rate for Payer: Cash Price |
$64.75
|
| Rate for Payer: Cigna of CA HMO |
$100.72
|
| Rate for Payer: Cigna of CA PPO |
$100.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$122.30
|
| Rate for Payer: Dignity Health Media |
$122.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$122.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$57.55
|
| Rate for Payer: Galaxy Health WC |
$122.30
|
| Rate for Payer: Global Benefits Group Commercial |
$86.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$107.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$95.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$245.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.53
|
| Rate for Payer: Multiplan Commercial |
$115.10
|
| Rate for Payer: Networks By Design Commercial |
$71.94
|
| Rate for Payer: Prime Health Services Commercial |
$122.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$86.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$86.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.94
|
| Rate for Payer: United Healthcare All Other HMO |
$71.94
|
| Rate for Payer: United Healthcare HMO Rider |
$71.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$71.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$122.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$122.30
|
| Rate for Payer: Vantage Medical Group Senior |
$122.30
|
|
|
HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE [118915]
|
Facility
IP
|
$143.88
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
NDG118915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.53 |
| Max. Negotiated Rate |
$122.30 |
| Rate for Payer: Blue Shield of California Commercial |
$102.44
|
| Rate for Payer: Blue Shield of California EPN |
$73.67
|
| Rate for Payer: Cash Price |
$64.75
|
| Rate for Payer: Cigna of CA HMO |
$100.72
|
| Rate for Payer: Cigna of CA PPO |
$100.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$57.55
|
| Rate for Payer: Galaxy Health WC |
$122.30
|
| Rate for Payer: Global Benefits Group Commercial |
$86.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$95.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.53
|
| Rate for Payer: Multiplan Commercial |
$115.10
|
| Rate for Payer: Networks By Design Commercial |
$71.94
|
| Rate for Payer: Prime Health Services Commercial |
$122.30
|
|
|
HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [118741]
|
Facility
IP
|
$94.75
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
1726016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.74 |
| Max. Negotiated Rate |
$80.54 |
| Rate for Payer: Blue Shield of California Commercial |
$67.46
|
| Rate for Payer: Blue Shield of California EPN |
$48.51
|
| Rate for Payer: Cash Price |
$42.64
|
| Rate for Payer: Cigna of CA HMO |
$66.32
|
| Rate for Payer: Cigna of CA PPO |
$66.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.90
|
| Rate for Payer: Galaxy Health WC |
$80.54
|
| Rate for Payer: Global Benefits Group Commercial |
$56.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.74
|
| Rate for Payer: Multiplan Commercial |
$75.80
|
| Rate for Payer: Networks By Design Commercial |
$47.38
|
| Rate for Payer: Prime Health Services Commercial |
$80.54
|
|
|
HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [118741]
|
Facility
OP
|
$94.75
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
1726016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.74 |
| Max. Negotiated Rate |
$488.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$488.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$80.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$131.90
|
| Rate for Payer: BCBS Transplant Transplant |
$56.85
|
| Rate for Payer: Blue Shield of California Commercial |
$69.83
|
| Rate for Payer: Blue Shield of California EPN |
$85.80
|
| Rate for Payer: Cash Price |
$42.64
|
| Rate for Payer: Cash Price |
$42.64
|
| Rate for Payer: Cigna of CA HMO |
$66.32
|
| Rate for Payer: Cigna of CA PPO |
$66.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.54
|
| Rate for Payer: Dignity Health Media |
$80.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.90
|
| Rate for Payer: Galaxy Health WC |
$80.54
|
| Rate for Payer: Global Benefits Group Commercial |
$56.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$71.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.74
|
| Rate for Payer: Multiplan Commercial |
$75.80
|
| Rate for Payer: Networks By Design Commercial |
$47.38
|
| Rate for Payer: Prime Health Services Commercial |
$80.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.38
|
| Rate for Payer: United Healthcare All Other HMO |
$47.38
|
| Rate for Payer: United Healthcare HMO Rider |
$47.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.54
|
| Rate for Payer: Vantage Medical Group Senior |
$80.54
|
|
|
HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]
|
Facility
IP
|
$170.29
|
|
|
Service Code
|
CPT 90371
|
| Hospital Charge Code |
1720099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$144.75 |
| Rate for Payer: Blue Shield of California Commercial |
$121.25
|
| Rate for Payer: Blue Shield of California EPN |
$87.19
|
| Rate for Payer: Cash Price |
$76.63
|
| Rate for Payer: Cigna of CA HMO |
$119.20
|
| Rate for Payer: Cigna of CA PPO |
$119.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$68.12
|
| Rate for Payer: Galaxy Health WC |
$144.75
|
| Rate for Payer: Global Benefits Group Commercial |
$102.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$113.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.87
|
| Rate for Payer: Multiplan Commercial |
$136.23
|
| Rate for Payer: Networks By Design Commercial |
$85.14
|
| Rate for Payer: Prime Health Services Commercial |
$144.75
|
|
|
HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]
|
Facility
OP
|
$170.29
|
|
|
Service Code
|
CPT 90371
|
| Hospital Charge Code |
1720099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$958.64 |
| Rate for Payer: Networks By Design Commercial |
$85.14
|
| Rate for Payer: Multiplan Commercial |
$136.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$958.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$172.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$151.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$151.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.79
|
| Rate for Payer: BCBS Transplant Transplant |
$102.17
|
| Rate for Payer: Blue Shield of California Commercial |
$125.50
|
| Rate for Payer: Blue Shield of California EPN |
$162.18
|
| Rate for Payer: Cash Price |
$76.63
|
| Rate for Payer: Cash Price |
$76.63
|
| Rate for Payer: Cigna of CA HMO |
$119.20
|
| Rate for Payer: Cigna of CA PPO |
$119.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.84
|
| Rate for Payer: Dignity Health Media |
$137.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$186.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$137.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$137.89
|
| Rate for Payer: Galaxy Health WC |
$144.75
|
| Rate for Payer: Global Benefits Group Commercial |
$102.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$127.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$226.14
|
| Rate for Payer: Heritage Provider Network Transplant |
$226.14
|
| Rate for Payer: IEHP Medi-Cal |
$223.39
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$223.39
|
| Rate for Payer: IEHP Medicare Advantage |
$137.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$113.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$270.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$184.78
|
| Rate for Payer: Prime Health Services Commercial |
$144.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$102.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$102.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$85.14
|
| Rate for Payer: United Healthcare All Other HMO |
$85.14
|
| Rate for Payer: United Healthcare HMO Rider |
$85.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.68
|
| Rate for Payer: Vantage Medical Group Senior |
$137.89
|
|
|
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE [222472]
|
Facility
OP
|
$337.44
|
|
|
Service Code
|
CPT 90739
|
| Hospital Charge Code |
NDG222472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.99 |
| Max. Negotiated Rate |
$1,114.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,114.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$286.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$185.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$185.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$269.63
|
| Rate for Payer: BCBS Transplant Transplant |
$202.46
|
| Rate for Payer: Blue Shield of California Commercial |
$248.69
|
| Rate for Payer: Blue Shield of California EPN |
$144.60
|
| Rate for Payer: Cash Price |
$151.85
|
| Rate for Payer: Cash Price |
$151.85
|
| Rate for Payer: Cigna of CA HMO |
$236.21
|
| Rate for Payer: Cigna of CA PPO |
$236.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$286.82
|
| Rate for Payer: Dignity Health Media |
$286.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$286.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$134.98
|
| Rate for Payer: Galaxy Health WC |
$286.82
|
| Rate for Payer: Global Benefits Group Commercial |
$202.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$253.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$225.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$313.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.99
|
| Rate for Payer: Multiplan Commercial |
$269.95
|
| Rate for Payer: Networks By Design Commercial |
$168.72
|
| Rate for Payer: Prime Health Services Commercial |
$286.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$202.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$202.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.72
|
| Rate for Payer: United Healthcare All Other HMO |
$168.72
|
| Rate for Payer: United Healthcare HMO Rider |
$168.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$286.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$286.82
|
| Rate for Payer: Vantage Medical Group Senior |
$286.82
|
|
|
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE [222472]
|
Facility
IP
|
$337.44
|
|
|
Service Code
|
CPT 90739
|
| Hospital Charge Code |
NDG222472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.99 |
| Max. Negotiated Rate |
$286.82 |
| Rate for Payer: Blue Shield of California Commercial |
$240.26
|
| Rate for Payer: Blue Shield of California EPN |
$172.77
|
| Rate for Payer: Cash Price |
$151.85
|
| Rate for Payer: Cigna of CA HMO |
$236.21
|
| Rate for Payer: Cigna of CA PPO |
$236.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$134.98
|
| Rate for Payer: Galaxy Health WC |
$286.82
|
| Rate for Payer: Global Benefits Group Commercial |
$202.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$225.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.99
|
| Rate for Payer: Multiplan Commercial |
$269.95
|
| Rate for Payer: Networks By Design Commercial |
$168.72
|
| Rate for Payer: Prime Health Services Commercial |
$286.82
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [118672]
|
Facility
OP
|
$63.86
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
1720519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$213.92 |
| Rate for Payer: Galaxy Health WC |
$54.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$213.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$54.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$35.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.02
|
| Rate for Payer: BCBS Transplant Transplant |
$38.32
|
| Rate for Payer: Blue Shield of California Commercial |
$47.06
|
| Rate for Payer: Blue Shield of California EPN |
$29.69
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cigna of CA HMO |
$44.70
|
| Rate for Payer: Cigna of CA PPO |
$44.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.28
|
| Rate for Payer: Dignity Health Media |
$54.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$25.54
|
| Rate for Payer: Global Benefits Group Commercial |
$38.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$47.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.33
|
| Rate for Payer: Multiplan Commercial |
$51.09
|
| Rate for Payer: Networks By Design Commercial |
$31.93
|
| Rate for Payer: Prime Health Services Commercial |
$54.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$38.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$38.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.93
|
| Rate for Payer: United Healthcare All Other HMO |
$31.93
|
| Rate for Payer: United Healthcare HMO Rider |
$31.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.28
|
| Rate for Payer: Vantage Medical Group Senior |
$54.28
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [118672]
|
Facility
IP
|
$63.86
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
1720519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Blue Shield of California Commercial |
$45.47
|
| Rate for Payer: Blue Shield of California EPN |
$32.70
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cigna of CA HMO |
$44.70
|
| Rate for Payer: Cigna of CA PPO |
$44.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$25.54
|
| Rate for Payer: Galaxy Health WC |
$54.28
|
| Rate for Payer: Global Benefits Group Commercial |
$38.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.33
|
| Rate for Payer: Multiplan Commercial |
$51.09
|
| Rate for Payer: Networks By Design Commercial |
$31.93
|
| Rate for Payer: Prime Health Services Commercial |
$54.28
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML INTRAMUSCULAR. [4081931]
|
Facility
OP
|
$63.86
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
1720519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$213.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$213.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$54.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$35.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.02
|
| Rate for Payer: BCBS Transplant Transplant |
$38.32
|
| Rate for Payer: Blue Shield of California Commercial |
$47.06
|
| Rate for Payer: Blue Shield of California EPN |
$29.69
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cigna of CA HMO |
$44.70
|
| Rate for Payer: Cigna of CA PPO |
$44.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.28
|
| Rate for Payer: Dignity Health Media |
$54.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$25.54
|
| Rate for Payer: Galaxy Health WC |
$54.28
|
| Rate for Payer: Global Benefits Group Commercial |
$38.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$47.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.33
|
| Rate for Payer: Multiplan Commercial |
$51.09
|
| Rate for Payer: Networks By Design Commercial |
$31.93
|
| Rate for Payer: Prime Health Services Commercial |
$54.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$38.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$38.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.93
|
| Rate for Payer: United Healthcare All Other HMO |
$31.93
|
| Rate for Payer: United Healthcare HMO Rider |
$31.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.28
|
| Rate for Payer: Vantage Medical Group Senior |
$54.28
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML INTRAMUSCULAR. [4081931]
|
Facility
IP
|
$63.86
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
1720519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Blue Shield of California Commercial |
$45.47
|
| Rate for Payer: Blue Shield of California EPN |
$32.70
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cigna of CA HMO |
$44.70
|
| Rate for Payer: Cigna of CA PPO |
$44.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$25.54
|
| Rate for Payer: Galaxy Health WC |
$54.28
|
| Rate for Payer: Global Benefits Group Commercial |
$38.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.33
|
| Rate for Payer: Multiplan Commercial |
$51.09
|
| Rate for Payer: Networks By Design Commercial |
$31.93
|
| Rate for Payer: Prime Health Services Commercial |
$54.28
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/ML INTRAMUSCULAR SUSP [119731]
|
Facility
IP
|
$76.98
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
NDG119731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$65.43 |
| Rate for Payer: Blue Shield of California Commercial |
$54.81
|
| Rate for Payer: Blue Shield of California EPN |
$39.41
|
| Rate for Payer: Cash Price |
$34.64
|
| Rate for Payer: Cigna of CA HMO |
$53.89
|
| Rate for Payer: Cigna of CA PPO |
$53.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$30.79
|
| Rate for Payer: Galaxy Health WC |
$65.43
|
| Rate for Payer: Global Benefits Group Commercial |
$46.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$51.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.48
|
| Rate for Payer: Multiplan Commercial |
$61.58
|
| Rate for Payer: Networks By Design Commercial |
$38.49
|
| Rate for Payer: Prime Health Services Commercial |
$65.43
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/ML INTRAMUSCULAR SUSP [119731]
|
Facility
OP
|
$76.98
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
NDG119731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$213.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$213.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$65.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.02
|
| Rate for Payer: BCBS Transplant Transplant |
$46.19
|
| Rate for Payer: Blue Shield of California Commercial |
$56.73
|
| Rate for Payer: Blue Shield of California EPN |
$29.69
|
| Rate for Payer: Cash Price |
$34.64
|
| Rate for Payer: Cash Price |
$34.64
|
| Rate for Payer: Cigna of CA HMO |
$53.89
|
| Rate for Payer: Cigna of CA PPO |
$53.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.43
|
| Rate for Payer: Dignity Health Media |
$65.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$30.79
|
| Rate for Payer: Galaxy Health WC |
$65.43
|
| Rate for Payer: Global Benefits Group Commercial |
$46.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$57.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$51.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.48
|
| Rate for Payer: Multiplan Commercial |
$61.58
|
| Rate for Payer: Networks By Design Commercial |
$38.49
|
| Rate for Payer: Prime Health Services Commercial |
$65.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$46.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$46.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.49
|
| Rate for Payer: United Healthcare All Other HMO |
$38.49
|
| Rate for Payer: United Healthcare HMO Rider |
$38.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.43
|
| Rate for Payer: Vantage Medical Group Senior |
$65.43
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [118608]
|
Facility
OP
|
$79.32
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
1720633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$489.30 |
| Rate for Payer: United Healthcare HMO Rider |
$39.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$489.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$67.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.86
|
| Rate for Payer: BCBS Transplant Transplant |
$47.59
|
| Rate for Payer: Blue Shield of California Commercial |
$58.46
|
| Rate for Payer: Blue Shield of California EPN |
$72.94
|
| Rate for Payer: Cash Price |
$35.69
|
| Rate for Payer: Cash Price |
$35.69
|
| Rate for Payer: Cigna of CA HMO |
$55.52
|
| Rate for Payer: Cigna of CA PPO |
$55.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.42
|
| Rate for Payer: Dignity Health Media |
$67.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$67.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$31.73
|
| Rate for Payer: Galaxy Health WC |
$67.42
|
| Rate for Payer: Global Benefits Group Commercial |
$47.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$59.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$63.46
|
| Rate for Payer: Networks By Design Commercial |
$39.66
|
| Rate for Payer: Prime Health Services Commercial |
$67.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$47.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$47.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.66
|
| Rate for Payer: United Healthcare All Other HMO |
$39.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$67.42
|
| Rate for Payer: Vantage Medical Group Senior |
$67.42
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [118608]
|
Facility
IP
|
$79.32
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
1720633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$67.42 |
| Rate for Payer: Blue Shield of California Commercial |
$56.48
|
| Rate for Payer: Blue Shield of California EPN |
$40.61
|
| Rate for Payer: Cash Price |
$35.69
|
| Rate for Payer: Cigna of CA HMO |
$55.52
|
| Rate for Payer: Cigna of CA PPO |
$55.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$31.73
|
| Rate for Payer: Galaxy Health WC |
$67.42
|
| Rate for Payer: Global Benefits Group Commercial |
$47.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$63.46
|
| Rate for Payer: Networks By Design Commercial |
$39.66
|
| Rate for Payer: Prime Health Services Commercial |
$67.42
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP [108150]
|
Facility
IP
|
$210.43
|
|
|
Service Code
|
CPT 90740
|
| Hospital Charge Code |
1722054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$178.87 |
| Rate for Payer: Blue Shield of California Commercial |
$149.83
|
| Rate for Payer: Blue Shield of California EPN |
$107.74
|
| Rate for Payer: Cash Price |
$94.69
|
| Rate for Payer: Cigna of CA HMO |
$147.30
|
| Rate for Payer: Cigna of CA PPO |
$147.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$84.17
|
| Rate for Payer: Galaxy Health WC |
$178.87
|
| Rate for Payer: Global Benefits Group Commercial |
$126.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$140.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.50
|
| Rate for Payer: Multiplan Commercial |
$168.34
|
| Rate for Payer: Networks By Design Commercial |
$105.22
|
| Rate for Payer: Prime Health Services Commercial |
$178.87
|
|
|
HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP [108150]
|
Facility
OP
|
$210.43
|
|
|
Service Code
|
CPT 90740
|
| Hospital Charge Code |
1722054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$1,057.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,057.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$178.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$115.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$115.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$417.53
|
| Rate for Payer: BCBS Transplant Transplant |
$126.26
|
| Rate for Payer: Blue Shield of California Commercial |
$155.09
|
| Rate for Payer: Blue Shield of California EPN |
$199.10
|
| Rate for Payer: Cash Price |
$94.69
|
| Rate for Payer: Cash Price |
$94.69
|
| Rate for Payer: Cigna of CA HMO |
$147.30
|
| Rate for Payer: Cigna of CA PPO |
$147.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$178.87
|
| Rate for Payer: Dignity Health Media |
$178.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$178.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$84.17
|
| Rate for Payer: Galaxy Health WC |
$178.87
|
| Rate for Payer: Global Benefits Group Commercial |
$126.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$157.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$140.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$297.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.50
|
| Rate for Payer: Multiplan Commercial |
$168.34
|
| Rate for Payer: Networks By Design Commercial |
$105.22
|
| Rate for Payer: Prime Health Services Commercial |
$178.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.22
|
| Rate for Payer: United Healthcare All Other HMO |
$105.22
|
| Rate for Payer: United Healthcare HMO Rider |
$105.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$105.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$178.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$178.87
|
| Rate for Payer: Vantage Medical Group Senior |
$178.87
|
|
|
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]
|
Facility
OP
|
$213.32
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
1721119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$663.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$663.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$181.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$117.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$117.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.79
|
| Rate for Payer: BCBS Transplant Transplant |
$127.99
|
| Rate for Payer: Blue Shield of California Commercial |
$157.22
|
| Rate for Payer: Blue Shield of California EPN |
$98.75
|
| Rate for Payer: Cash Price |
$95.99
|
| Rate for Payer: Cash Price |
$95.99
|
| Rate for Payer: Cigna of CA HMO |
$149.32
|
| Rate for Payer: Cigna of CA PPO |
$149.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$181.32
|
| Rate for Payer: Dignity Health Media |
$181.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$85.33
|
| Rate for Payer: Galaxy Health WC |
$181.32
|
| Rate for Payer: Global Benefits Group Commercial |
$127.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$159.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$142.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$187.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.20
|
| Rate for Payer: Multiplan Commercial |
$170.66
|
| Rate for Payer: Networks By Design Commercial |
$106.66
|
| Rate for Payer: Prime Health Services Commercial |
$181.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.66
|
| Rate for Payer: United Healthcare All Other HMO |
$106.66
|
| Rate for Payer: United Healthcare HMO Rider |
$106.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$181.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.32
|
| Rate for Payer: Vantage Medical Group Senior |
$181.32
|
|
|
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]
|
Facility
IP
|
$213.32
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
1721119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$181.32 |
| Rate for Payer: Blue Shield of California Commercial |
$151.88
|
| Rate for Payer: Blue Shield of California EPN |
$109.22
|
| Rate for Payer: Cash Price |
$95.99
|
| Rate for Payer: Cigna of CA HMO |
$149.32
|
| Rate for Payer: Cigna of CA PPO |
$149.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$85.33
|
| Rate for Payer: Galaxy Health WC |
$181.32
|
| Rate for Payer: Global Benefits Group Commercial |
$127.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$142.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.20
|
| Rate for Payer: Multiplan Commercial |
$170.66
|
| Rate for Payer: Networks By Design Commercial |
$106.66
|
| Rate for Payer: Prime Health Services Commercial |
$181.32
|
|
|
HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL
|
Facility
IP
|
$59,951.82
|
|
|
Service Code
|
APR-DRG 2274
|
| Min. Negotiated Rate |
$45,989.36 |
| Max. Negotiated Rate |
$59,951.82 |
| Rate for Payer: IEHP Medi-Cal |
$45,989.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59,951.82
|
|
|
HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL
|
Facility
IP
|
$18,614.24
|
|
|
Service Code
|
APR-DRG 2271
|
| Min. Negotiated Rate |
$14,279.08 |
| Max. Negotiated Rate |
$18,614.24 |
| Rate for Payer: IEHP Medi-Cal |
$14,279.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,614.24
|
|
|
HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL
|
Facility
IP
|
$32,910.09
|
|
|
Service Code
|
APR-DRG 2273
|
| Min. Negotiated Rate |
$25,245.50 |
| Max. Negotiated Rate |
$32,910.09 |
| Rate for Payer: IEHP Medi-Cal |
$25,245.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32,910.09
|
|
|
HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL
|
Facility
IP
|
$23,285.53
|
|
|
Service Code
|
APR-DRG 2272
|
| Min. Negotiated Rate |
$17,862.45 |
| Max. Negotiated Rate |
$23,285.53 |
| Rate for Payer: IEHP Medi-Cal |
$17,862.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,285.53
|
|
