|
HIV WITH MAJOR RELATED CONDITION WITH CC
|
Facility
|
IP
|
$34,083.11
|
|
|
Service Code
|
MSDRG 975
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$34,083.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$34,083.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22,016.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30,823.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$30,957.81
|
| Rate for Payer: EPIC Health Plan Senior |
$20,638.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,762.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,267.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,141.50
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$18,762.31
|
| Rate for Payer: Prime Health Services Medicare |
$19,888.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
HIV WITH MAJOR RELATED CONDITION WITH MCC
|
Facility
|
IP
|
$75,956.63
|
|
|
Service Code
|
MSDRG 974
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$75,956.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$75,956.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$49,064.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$68,692.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$67,164.01
|
| Rate for Payer: EPIC Health Plan Senior |
$44,776.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$40,705.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56,987.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$54,545.32
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$40,705.46
|
| Rate for Payer: Prime Health Services Medicare |
$43,147.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC
|
Facility
|
IP
|
$23,542.35
|
|
|
Service Code
|
MSDRG 976
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$23,542.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,542.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15,207.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21,290.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,030.29
|
| Rate for Payer: EPIC Health Plan Senior |
$14,686.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,351.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,692.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,891.26
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$13,351.69
|
| Rate for Payer: Prime Health Services Medicare |
$14,152.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$24,963.87
|
|
|
Service Code
|
APR-DRG 8903
|
| Min. Negotiated Rate |
$15,766.66 |
| Max. Negotiated Rate |
$24,963.87 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,766.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$18,788.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24,963.87
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$11,243.21
|
|
|
Service Code
|
APR-DRG 8901
|
| Min. Negotiated Rate |
$7,100.98 |
| Max. Negotiated Rate |
$11,243.21 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,100.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,462.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,243.21
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$46,922.57
|
|
|
Service Code
|
APR-DRG 8904
|
| Min. Negotiated Rate |
$29,635.31 |
| Max. Negotiated Rate |
$46,922.57 |
| Rate for Payer: Adventist Health Medi-Cal |
$29,635.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$35,315.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46,922.57
|
|
|
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS
|
Facility
|
IP
|
$15,454.89
|
|
|
Service Code
|
APR-DRG 8902
|
| Min. Negotiated Rate |
$9,760.98 |
| Max. Negotiated Rate |
$15,454.89 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,760.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11,631.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,454.89
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$17,328.08
|
|
|
Service Code
|
APR-DRG 8933
|
| Min. Negotiated Rate |
$10,944.05 |
| Max. Negotiated Rate |
$17,328.08 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,944.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,041.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17,328.08
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$29,499.82
|
|
|
Service Code
|
APR-DRG 8934
|
| Min. Negotiated Rate |
$18,631.46 |
| Max. Negotiated Rate |
$29,499.82 |
| Rate for Payer: Adventist Health Medi-Cal |
$18,631.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$22,202.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29,499.82
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$14,048.98
|
|
|
Service Code
|
APR-DRG 8932
|
| Min. Negotiated Rate |
$8,873.04 |
| Max. Negotiated Rate |
$14,048.98 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,873.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$10,573.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,048.98
|
|
|
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
|
Facility
|
IP
|
$10,767.85
|
|
|
Service Code
|
APR-DRG 8931
|
| Min. Negotiated Rate |
$6,800.75 |
| Max. Negotiated Rate |
$10,767.85 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,800.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,104.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10,767.85
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$9,104.14
|
|
|
Service Code
|
APR-DRG 8941
|
| Min. Negotiated Rate |
$5,749.98 |
| Max. Negotiated Rate |
$9,104.14 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,749.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,852.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9,104.14
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$11,206.96
|
|
|
Service Code
|
APR-DRG 8942
|
| Min. Negotiated Rate |
$7,078.08 |
| Max. Negotiated Rate |
$11,206.96 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,078.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,434.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,206.96
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$25,312.33
|
|
|
Service Code
|
APR-DRG 8944
|
| Min. Negotiated Rate |
$15,986.74 |
| Max. Negotiated Rate |
$25,312.33 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,986.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$19,050.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25,312.33
|
|
|
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS
|
Facility
|
IP
|
$15,150.73
|
|
|
Service Code
|
APR-DRG 8943
|
| Min. Negotiated Rate |
$9,568.88 |
| Max. Negotiated Rate |
$15,150.73 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,568.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11,402.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,150.73
|
|
|
HIV WITH OR WITHOUT OTHER RELATED CONDITION
|
Facility
|
IP
|
$33,361.96
|
|
|
Service Code
|
MSDRG 977
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$33,361.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$33,361.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21,550.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30,171.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$31,019.26
|
| Rate for Payer: EPIC Health Plan Senior |
$20,679.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,799.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,319.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,191.40
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$18,799.55
|
| Rate for Payer: Prime Health Services Medicare |
$19,927.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
HS OS STRIP BARRIER ELASTIC
|
Facility
|
OP
|
$5.99
|
|
|
Service Code
|
CPT A4362
|
| Hospital Charge Code |
901606455
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.71 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.48
|
| Rate for Payer: Blue Shield of California Commercial |
$3.80
|
| Rate for Payer: Blue Shield of California EPN |
$2.39
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.79
|
| Rate for Payer: Cigna of CA HMO |
$3.83
|
| Rate for Payer: Cigna of CA PPO |
$4.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.09
|
| Rate for Payer: Global Benefits Group Commercial |
$3.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Networks By Design Commercial |
$3.89
|
| Rate for Payer: Prime Health Services Commercial |
$5.09
|
| Rate for Payer: Riverside University Health System MISP |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.09
|
| Rate for Payer: Vantage Medical Group Senior |
$5.09
|
|
|
HS OS STRIP BARRIER ELASTIC
|
Facility
|
IP
|
$5.99
|
|
|
Service Code
|
CPT A4362
|
| Hospital Charge Code |
901606455
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.09
|
| Rate for Payer: Global Benefits Group Commercial |
$3.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Networks By Design Commercial |
$3.89
|
| Rate for Payer: Prime Health Services Commercial |
$5.09
|
|
|
HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]
|
Facility
|
OP
|
$788.02
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.60 |
| Max. Negotiated Rate |
$1,924.34 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,924.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$669.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$433.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$591.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$328.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$410.48
|
| Rate for Payer: Blue Shield of California Commercial |
$405.88
|
| Rate for Payer: Blue Shield of California EPN |
$368.98
|
| Rate for Payer: Cash Price |
$354.61
|
| Rate for Payer: Cash Price |
$354.61
|
| Rate for Payer: Central Health Plan Commercial |
$630.42
|
| Rate for Payer: Cigna of CA HMO |
$551.61
|
| Rate for Payer: Cigna of CA PPO |
$551.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$669.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$669.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$551.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$315.21
|
| Rate for Payer: EPIC Health Plan Senior |
$315.21
|
| Rate for Payer: Galaxy Health WC |
$669.82
|
| Rate for Payer: Global Benefits Group Commercial |
$472.81
|
| Rate for Payer: Health Management Network EPO/PPO |
$709.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$572.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$500.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$632.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$464.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$551.61
|
| Rate for Payer: Multiplan Commercial |
$591.01
|
| Rate for Payer: Networks By Design Commercial |
$394.01
|
| Rate for Payer: Prime Health Services Commercial |
$669.82
|
| Rate for Payer: Riverside University Health System MISP |
$315.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$472.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$472.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$295.74
|
| Rate for Payer: United Healthcare All Other HMO |
$287.86
|
| Rate for Payer: United Healthcare HMO Rider |
$281.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$258.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$669.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.82
|
| Rate for Payer: Vantage Medical Group Senior |
$669.82
|
|
|
HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]
|
Facility
|
IP
|
$788.02
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.60 |
| Max. Negotiated Rate |
$709.22 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Blue Shield of California Commercial |
$631.99
|
| Rate for Payer: Blue Shield of California EPN |
$397.16
|
| Rate for Payer: Cash Price |
$354.61
|
| Rate for Payer: Central Health Plan Commercial |
$630.42
|
| Rate for Payer: Cigna of CA HMO |
$551.61
|
| Rate for Payer: Cigna of CA PPO |
$551.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$551.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$315.21
|
| Rate for Payer: EPIC Health Plan Senior |
$315.21
|
| Rate for Payer: Galaxy Health WC |
$669.82
|
| Rate for Payer: Global Benefits Group Commercial |
$472.81
|
| Rate for Payer: Health Management Network EPO/PPO |
$709.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$500.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$464.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.60
|
| Rate for Payer: Multiplan Commercial |
$591.01
|
| Rate for Payer: Networks By Design Commercial |
$394.01
|
| Rate for Payer: Prime Health Services Commercial |
$669.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$295.74
|
| Rate for Payer: United Healthcare All Other HMO |
$287.86
|
| Rate for Payer: United Healthcare HMO Rider |
$281.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$258.08
|
|
|
HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]
|
Facility
|
IP
|
$3.58
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Central Health Plan Commercial |
$2.86
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: EPIC Health Plan Senior |
$1.43
|
| Rate for Payer: Galaxy Health WC |
$3.04
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| 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 |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1.31
|
| Rate for Payer: United Healthcare HMO Rider |
$1.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
|
|
HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]
|
Facility
|
OP
|
$3.58
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Medi-Cal |
$2.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.72
|
| Rate for Payer: Blue Shield of California Commercial |
$3.94
|
| Rate for Payer: Blue Shield of California EPN |
$3.58
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Central Health Plan Commercial |
$2.86
|
| 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 |
$2.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.32
|
| Rate for Payer: EPIC Health Plan Senior |
$2.21
|
| Rate for Payer: Galaxy Health WC |
$3.04
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.22
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2.01
|
| Rate for Payer: Prime Health Services Commercial |
$3.04
|
| Rate for Payer: Prime Health Services Medicare |
$2.13
|
| Rate for Payer: Riverside University Health System MISP |
$2.21
|
| 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 |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1.31
|
| Rate for Payer: United Healthcare HMO Rider |
$1.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 500 UNIT IV SOLUTION [239091]
|
Facility
|
IP
|
$3.78
|
|
|
Service Code
|
HCPCS J7165
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.91
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Central Health Plan Commercial |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$2.65
|
| Rate for Payer: Cigna of CA PPO |
$2.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.51
|
| Rate for Payer: EPIC Health Plan Senior |
$1.51
|
| Rate for Payer: Galaxy Health WC |
$3.21
|
| Rate for Payer: Global Benefits Group Commercial |
$2.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.83
|
| Rate for Payer: Networks By Design Commercial |
$1.89
|
| Rate for Payer: Prime Health Services Commercial |
$3.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.24
|
|
|
HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 500 UNIT IV SOLUTION [239091]
|
Facility
|
OP
|
$3.78
|
|
|
Service Code
|
HCPCS J7165
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$19.27 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Adventist Health Medi-Cal |
$1.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.84
|
| Rate for Payer: Blue Shield of California Commercial |
$4.16
|
| Rate for Payer: Blue Shield of California EPN |
$3.78
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Central Health Plan Commercial |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$2.65
|
| Rate for Payer: Cigna of CA PPO |
$2.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: EPIC Health Plan Senior |
$1.90
|
| Rate for Payer: Galaxy Health WC |
$3.21
|
| Rate for Payer: Global Benefits Group Commercial |
$2.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$2.83
|
| Rate for Payer: Networks By Design Commercial |
$1.89
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$1.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.21
|
| Rate for Payer: Prime Health Services Medicare |
$1.83
|
| Rate for Payer: Riverside University Health System MISP |
$1.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.24
|
| Rate for Payer: Upland Medical Group Pediatric |
$1.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]
|
Facility
|
OP
|
$66.96
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$60.26 |
| Rate for Payer: Adventist Health Commercial |
$13.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.27
|
| 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 |
$50.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| 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: Central Health Plan Commercial |
$53.57
|
| 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 Medi-Cal |
$56.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$56.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$46.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.78
|
| Rate for Payer: EPIC Health Plan Senior |
$26.78
|
| Rate for Payer: Galaxy Health WC |
$56.92
|
| Rate for Payer: Global Benefits Group Commercial |
$40.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$42.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$39.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$46.87
|
| Rate for Payer: Multiplan Commercial |
$50.22
|
| Rate for Payer: Networks By Design Commercial |
$33.48
|
| Rate for Payer: Prime Health Services Commercial |
$56.92
|
| Rate for Payer: Riverside University Health System MISP |
$26.78
|
| 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 |
$25.13
|
| Rate for Payer: United Healthcare All Other HMO |
$24.46
|
| Rate for Payer: United Healthcare HMO Rider |
$23.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.93
|
| 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
|
|
