|
HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [25174]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 0264-1965-10
|
| Hospital Charge Code |
1771089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [25174]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 0264-1965-10
|
| Hospital Charge Code |
1771089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
HIP AND FEMUR FRACTURE REPAIR
|
Facility
IP
|
$48,422.54
|
|
|
Service Code
|
APR-DRG 3084
|
| Min. Negotiated Rate |
$37,145.19 |
| Max. Negotiated Rate |
$48,422.54 |
| Rate for Payer: IEHP Medi-Cal |
$37,145.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48,422.54
|
|
|
HIP AND FEMUR FRACTURE REPAIR
|
Facility
IP
|
$33,504.20
|
|
|
Service Code
|
APR-DRG 3083
|
| Min. Negotiated Rate |
$25,701.25 |
| Max. Negotiated Rate |
$33,504.20 |
| Rate for Payer: IEHP Medi-Cal |
$25,701.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33,504.20
|
|
|
HIP AND FEMUR FRACTURE REPAIR
|
Facility
IP
|
$26,094.70
|
|
|
Service Code
|
APR-DRG 3082
|
| Min. Negotiated Rate |
$20,017.38 |
| Max. Negotiated Rate |
$26,094.70 |
| Rate for Payer: IEHP Medi-Cal |
$20,017.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26,094.70
|
|
|
HIP AND FEMUR FRACTURE REPAIR
|
Facility
IP
|
$22,122.14
|
|
|
Service Code
|
APR-DRG 3081
|
| Min. Negotiated Rate |
$16,970.01 |
| Max. Negotiated Rate |
$22,122.14 |
| Rate for Payer: IEHP Medi-Cal |
$16,970.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,122.14
|
|
|
HIV WITH MAJOR HIV RELATED CONDITION
|
Facility
IP
|
$24,741.53
|
|
|
Service Code
|
APR-DRG 8924
|
| Min. Negotiated Rate |
$18,979.36 |
| Max. Negotiated Rate |
$24,741.53 |
| Rate for Payer: IEHP Medi-Cal |
$18,979.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,741.53
|
|
|
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: 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
|
$11,481.38
|
|
|
Service Code
|
APR-DRG 8922
|
| Min. Negotiated Rate |
$8,807.42 |
| Max. Negotiated Rate |
$11,481.38 |
| Rate for Payer: IEHP Medi-Cal |
$8,807.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,481.38
|
|
|
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: 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
|
$13,565.20
|
|
|
Service Code
|
APR-DRG 8902
|
| Min. Negotiated Rate |
$10,405.94 |
| Max. Negotiated Rate |
$13,565.20 |
| Rate for Payer: IEHP Medi-Cal |
$10,405.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,565.20
|
|
|
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: 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
|
$20,236.96
|
|
|
Service Code
|
APR-DRG 8903
|
| Min. Negotiated Rate |
$15,523.88 |
| Max. Negotiated Rate |
$20,236.96 |
| Rate for Payer: 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
|
$12,885.95
|
|
|
Service Code
|
APR-DRG 8901
|
| Min. Negotiated Rate |
$9,884.88 |
| Max. Negotiated Rate |
$12,885.95 |
| Rate for Payer: IEHP Medi-Cal |
$9,884.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,885.95
|
|
|
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: IEHP Medi-Cal |
$9,891.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,894.82
|
|
|
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: 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
|
$27,477.99
|
|
|
Service Code
|
APR-DRG 8934
|
| Min. Negotiated Rate |
$21,078.51 |
| Max. Negotiated Rate |
$27,477.99 |
| Rate for Payer: 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
|
$18,000.62
|
|
|
Service Code
|
APR-DRG 8933
|
| Min. Negotiated Rate |
$13,808.37 |
| Max. Negotiated Rate |
$18,000.62 |
| Rate for Payer: IEHP Medi-Cal |
$13,808.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,000.62
|
|
|
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: 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
|
$8,776.86
|
|
|
Service Code
|
APR-DRG 8941
|
| Min. Negotiated Rate |
$6,732.78 |
| Max. Negotiated Rate |
$8,776.86 |
| Rate for Payer: 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: IEHP Medi-Cal |
$18,840.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,560.65
|
|
|
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: IEHP Medi-Cal |
$8,426.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,984.81
|
|
|
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$546.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$353.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$353.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.26
|
| Rate for Payer: BCBS Transplant 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 Transplant 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
|
|
