|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
IP
|
$0.82
|
|
|
Service Code
|
NDC 43199-011-01
|
| Hospital Charge Code |
1711556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
OP
|
$0.54
|
|
|
Service Code
|
NDC 42192-339-01
|
| Hospital Charge Code |
1711556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: BCBS Transplant Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Media |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
IP
|
$80.30
|
|
|
Service Code
|
CPT J1980
|
| Hospital Charge Code |
1720837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.27 |
| Max. Negotiated Rate |
$68.26 |
| Rate for Payer: Blue Shield of California Commercial |
$57.17
|
| Rate for Payer: Blue Shield of California EPN |
$41.11
|
| Rate for Payer: Cash Price |
$36.14
|
| Rate for Payer: Cigna of CA HMO |
$56.21
|
| Rate for Payer: Cigna of CA PPO |
$56.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.12
|
| Rate for Payer: Galaxy Health WC |
$68.26
|
| Rate for Payer: Global Benefits Group Commercial |
$48.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.27
|
| Rate for Payer: Multiplan Commercial |
$64.24
|
| Rate for Payer: Networks By Design Commercial |
$40.15
|
| Rate for Payer: Prime Health Services Commercial |
$68.26
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
OP
|
$80.30
|
|
|
Service Code
|
CPT J1980
|
| Hospital Charge Code |
1720837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$223.06 |
| Rate for Payer: BCBS Transplant Transplant |
$48.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$223.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.47
|
| Rate for Payer: Blue Shield of California Commercial |
$59.18
|
| Rate for Payer: Blue Shield of California EPN |
$35.60
|
| Rate for Payer: Cash Price |
$36.14
|
| Rate for Payer: Cash Price |
$36.14
|
| Rate for Payer: Cigna of CA HMO |
$56.21
|
| Rate for Payer: Cigna of CA PPO |
$56.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.26
|
| Rate for Payer: Dignity Health Media |
$68.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.12
|
| Rate for Payer: Galaxy Health WC |
$68.26
|
| Rate for Payer: Global Benefits Group Commercial |
$48.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$60.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.27
|
| Rate for Payer: Multiplan Commercial |
$64.24
|
| Rate for Payer: Networks By Design Commercial |
$40.15
|
| Rate for Payer: Prime Health Services Commercial |
$68.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.15
|
| Rate for Payer: United Healthcare All Other HMO |
$40.15
|
| Rate for Payer: United Healthcare HMO Rider |
$40.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.26
|
| Rate for Payer: Vantage Medical Group Senior |
$68.26
|
|
|
HYPERTENSION
|
Facility
IP
|
$19,461.95
|
|
|
Service Code
|
APR-DRG 1994
|
| Min. Negotiated Rate |
$14,929.36 |
| Max. Negotiated Rate |
$19,461.95 |
| Rate for Payer: IEHP Medi-Cal |
$14,929.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19,461.95
|
|
|
HYPERTENSION
|
Facility
IP
|
$7,918.50
|
|
|
Service Code
|
APR-DRG 1991
|
| Min. Negotiated Rate |
$6,074.32 |
| Max. Negotiated Rate |
$7,918.50 |
| Rate for Payer: IEHP Medi-Cal |
$6,074.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,918.50
|
|
|
HYPERTENSION
|
Facility
IP
|
$13,327.55
|
|
|
Service Code
|
APR-DRG 1993
|
| Min. Negotiated Rate |
$10,223.63 |
| Max. Negotiated Rate |
$13,327.55 |
| Rate for Payer: IEHP Medi-Cal |
$10,223.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,327.55
|
|
|
HYPERTENSION
|
Facility
IP
|
$9,676.00
|
|
|
Service Code
|
APR-DRG 1992
|
| Min. Negotiated Rate |
$7,422.51 |
| Max. Negotiated Rate |
$9,676.00 |
| Rate for Payer: IEHP Medi-Cal |
$7,422.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,676.00
|
|
|
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS
|
Facility
IP
|
$20,066.70
|
|
|
Service Code
|
APR-DRG 4224
|
| Min. Negotiated Rate |
$15,393.27 |
| Max. Negotiated Rate |
$20,066.70 |
| Rate for Payer: IEHP Medi-Cal |
$15,393.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,066.70
|
|
|
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS
|
Facility
IP
|
$7,886.58
|
|
|
Service Code
|
APR-DRG 4222
|
| Min. Negotiated Rate |
$6,049.83 |
| Max. Negotiated Rate |
$7,886.58 |
| Rate for Payer: IEHP Medi-Cal |
$6,049.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,886.58
|
|
|
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS
|
Facility
IP
|
$11,479.61
|
|
|
Service Code
|
APR-DRG 4223
|
| Min. Negotiated Rate |
$8,806.07 |
| Max. Negotiated Rate |
$11,479.61 |
| Rate for Payer: IEHP Medi-Cal |
$8,806.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,479.61
|
|
|
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS
|
Facility
IP
|
$5,297.33
|
|
|
Service Code
|
APR-DRG 4221
|
| Min. Negotiated Rate |
$4,063.61 |
| Max. Negotiated Rate |
$5,297.33 |
| Rate for Payer: IEHP Medi-Cal |
$4,063.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,297.33
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS [38092]
|
Facility
OP
|
$1.55
|
|
|
Service Code
|
NDC 17478-064-12
|
| Hospital Charge Code |
1740135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.92
|
| Rate for Payer: BCBS Transplant Transplant |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.32
|
| Rate for Payer: Dignity Health Media |
$1.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Vantage Medical Group Senior |
$1.32
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS [38092]
|
Facility
IP
|
$1.55
|
|
|
Service Code
|
NDC 17478-064-12
|
| Hospital Charge Code |
1740135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$13,250.00
|
|
|
Service Code
|
ICD 02WA3NZ
|
| Min. Negotiated Rate |
$13,250.00 |
| Max. Negotiated Rate |
$13,250.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,250.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$13,250.00
|
|
|
Service Code
|
ICD 02H63NZ
|
| Min. Negotiated Rate |
$13,250.00 |
| Max. Negotiated Rate |
$13,250.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,250.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$13,250.00
|
|
|
Service Code
|
ICD 02H70NZ
|
| Min. Negotiated Rate |
$13,250.00 |
| Max. Negotiated Rate |
$13,250.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,250.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02RJ37Z
|
| Min. Negotiated Rate |
$11,541.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$24,272.00
|
|
|
Service Code
|
ICD 0UT24ZZ
|
| Min. Negotiated Rate |
$24,272.00 |
| Max. Negotiated Rate |
$24,272.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24,272.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$13,250.00
|
|
|
Service Code
|
ICD 02H63JZ
|
| Min. Negotiated Rate |
$13,250.00 |
| Max. Negotiated Rate |
$13,250.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,250.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$13,250.00
|
|
|
Service Code
|
ICD 02H40NZ
|
| Min. Negotiated Rate |
$13,250.00 |
| Max. Negotiated Rate |
$13,250.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,250.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$27,899.00
|
|
|
Service Code
|
ICD 09HD45Z
|
| Min. Negotiated Rate |
$27,899.00 |
| Max. Negotiated Rate |
$27,899.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,899.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02RJ38H
|
| Min. Negotiated Rate |
$11,541.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$27,899.00
|
|
|
Service Code
|
ICD 09HE45Z
|
| Min. Negotiated Rate |
$27,899.00 |
| Max. Negotiated Rate |
$27,899.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,899.00
|
|
|
IA Pacemaker - #2632
|
Facility
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02RJ37H
|
| Min. Negotiated Rate |
$11,541.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
|
