|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
IP
|
$19.24
|
|
|
Service Code
|
NDC 0527-2133-35
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.22
|
| Rate for Payer: Cash Price |
$8.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.03
|
| Rate for Payer: Heritage Provider Network Senior |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.81
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
OP
|
$56.60
|
|
|
Service Code
|
NDC 60687-523-21
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.24 |
| Max. Negotiated Rate |
$48.11 |
| Rate for Payer: Adventist Health Commercial |
$11.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.45
|
| Rate for Payer: Blue Shield of California Commercial |
$35.15
|
| Rate for Payer: Blue Shield of California EPN |
$33.22
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.11
|
| Rate for Payer: Dignity Health Senior |
$48.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.04
|
| Rate for Payer: Heritage Provider Network Senior |
$35.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.15
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.11
|
| Rate for Payer: Vantage Medical Group Senior |
$48.11
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
IP
|
$82.24
|
|
|
Service Code
|
NDC 0085-4324-02
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$61.68 |
| Rate for Payer: Adventist Health Commercial |
$16.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.50
|
| Rate for Payer: Cash Price |
$37.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.68
|
| Rate for Payer: Heritage Provider Network Senior |
$55.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.56
|
| Rate for Payer: Multiplan Commercial |
$61.68
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$5.59
|
| Rate for Payer: Blue Shield of California EPN |
$5.28
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Senior |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]
|
Facility
IP
|
$16.45
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
1715196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$12.34 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.30
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.14
|
| Rate for Payer: Heritage Provider Network Senior |
$11.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]
|
Facility
OP
|
$16.45
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
1715196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$13.98 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.22
|
| Rate for Payer: Blue Shield of California EPN |
$9.66
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.98
|
| Rate for Payer: Dignity Health Senior |
$13.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.18
|
| Rate for Payer: Heritage Provider Network Senior |
$10.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.98
|
| Rate for Payer: Vantage Medical Group Senior |
$13.98
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
IP
|
$38.12
|
|
|
Service Code
|
NDC 0085-4331-01
|
| Hospital Charge Code |
NDG2211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$28.59 |
| Rate for Payer: Adventist Health Commercial |
$7.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.19
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.81
|
| Rate for Payer: Heritage Provider Network Senior |
$25.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.53
|
| Rate for Payer: Multiplan Commercial |
$28.59
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
OP
|
$38.12
|
|
|
Service Code
|
NDC 0085-4331-01
|
| Hospital Charge Code |
NDG2211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$32.40 |
| Rate for Payer: Adventist Health Commercial |
$7.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$28.59
|
| Rate for Payer: Blue Shield of California Commercial |
$23.67
|
| Rate for Payer: Blue Shield of California EPN |
$22.38
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.40
|
| Rate for Payer: Dignity Health Senior |
$32.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.60
|
| Rate for Payer: Heritage Provider Network Senior |
$23.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.53
|
| Rate for Payer: Multiplan Commercial |
$28.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.40
|
| Rate for Payer: Vantage Medical Group Senior |
$32.40
|
|
|
Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
|
Facility
OP
|
$11,807.68
|
|
|
Service Code
|
CPT 57250
|
| Min. Negotiated Rate |
$553.32 |
| Max. Negotiated Rate |
$11,807.68 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,214.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,836.03
|
| Rate for Payer: Dignity Health Senior |
$6,214.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,214.57
|
| Rate for Payer: Humana Medicare |
$6,214.57
|
| Rate for Payer: IEHP Medi-Cal |
$553.32
|
| Rate for Payer: IEHP Medicare Advantage |
$6,214.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,807.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,333.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,830.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7,830.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,836.03
|
| Rate for Payer: TriValley Medical Group Senior |
$6,214.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$6,214.57
|
|
|
Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 22840
|
| Min. Negotiated Rate |
$573.81 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$573.81
|
|
|
Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 22842
|
| Min. Negotiated Rate |
$639.44 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$639.44
|
|
|
POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE
|
Facility
IP
|
$37,239.96
|
|
|
Service Code
|
APR-DRG 7114
|
| Min. Negotiated Rate |
$37,239.96 |
| Max. Negotiated Rate |
$37,239.96 |
| Rate for Payer: IEHP Medi-Cal |
$37,239.96
|
|
|
POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE
|
Facility
IP
|
$9,177.92
|
|
|
Service Code
|
APR-DRG 7111
|
| Min. Negotiated Rate |
$9,177.92 |
| Max. Negotiated Rate |
$9,177.92 |
| Rate for Payer: IEHP Medi-Cal |
$9,177.92
|
|
|
POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE
|
Facility
IP
|
$12,001.44
|
|
|
Service Code
|
APR-DRG 7112
|
| Min. Negotiated Rate |
$12,001.44 |
| Max. Negotiated Rate |
$12,001.44 |
| Rate for Payer: IEHP Medi-Cal |
$12,001.44
|
|
|
POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE
|
Facility
IP
|
$19,831.26
|
|
|
Service Code
|
APR-DRG 7113
|
| Min. Negotiated Rate |
$19,831.26 |
| Max. Negotiated Rate |
$19,831.26 |
| Rate for Payer: IEHP Medi-Cal |
$19,831.26
|
|
|
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS
|
Facility
IP
|
$4,890.91
|
|
|
Service Code
|
APR-DRG 7211
|
| Min. Negotiated Rate |
$4,890.91 |
| Max. Negotiated Rate |
$4,890.91 |
| Rate for Payer: IEHP Medi-Cal |
$4,890.91
|
|
|
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS
|
Facility
IP
|
$18,212.57
|
|
|
Service Code
|
APR-DRG 7214
|
| Min. Negotiated Rate |
$18,212.57 |
| Max. Negotiated Rate |
$18,212.57 |
| Rate for Payer: IEHP Medi-Cal |
$18,212.57
|
|
|
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS
|
Facility
IP
|
$10,164.85
|
|
|
Service Code
|
APR-DRG 7213
|
| Min. Negotiated Rate |
$10,164.85 |
| Max. Negotiated Rate |
$10,164.85 |
| Rate for Payer: IEHP Medi-Cal |
$10,164.85
|
|
|
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS
|
Facility
IP
|
$6,444.93
|
|
|
Service Code
|
APR-DRG 7212
|
| Min. Negotiated Rate |
$6,444.93 |
| Max. Negotiated Rate |
$6,444.93 |
| Rate for Payer: IEHP Medi-Cal |
$6,444.93
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE
|
Facility
IP
|
$12,026.20
|
|
|
Service Code
|
APR-DRG 5614
|
| Min. Negotiated Rate |
$12,026.20 |
| Max. Negotiated Rate |
$12,026.20 |
| Rate for Payer: IEHP Medi-Cal |
$12,026.20
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE
|
Facility
IP
|
$2,178.82
|
|
|
Service Code
|
APR-DRG 5611
|
| Min. Negotiated Rate |
$2,178.82 |
| Max. Negotiated Rate |
$2,178.82 |
| Rate for Payer: IEHP Medi-Cal |
$2,178.82
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE
|
Facility
IP
|
$3,308.03
|
|
|
Service Code
|
APR-DRG 5612
|
| Min. Negotiated Rate |
$3,308.03 |
| Max. Negotiated Rate |
$3,308.03 |
| Rate for Payer: IEHP Medi-Cal |
$3,308.03
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE
|
Facility
IP
|
$5,173.46
|
|
|
Service Code
|
APR-DRG 5613
|
| Min. Negotiated Rate |
$5,173.46 |
| Max. Negotiated Rate |
$5,173.46 |
| Rate for Payer: IEHP Medi-Cal |
$5,173.46
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
IP
|
$3,627.40
|
|
|
Service Code
|
APR-DRG 5481
|
| Min. Negotiated Rate |
$3,627.40 |
| Max. Negotiated Rate |
$3,627.40 |
| Rate for Payer: IEHP Medi-Cal |
$3,627.40
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
IP
|
$31,556.61
|
|
|
Service Code
|
APR-DRG 5484
|
| Min. Negotiated Rate |
$31,556.61 |
| Max. Negotiated Rate |
$31,556.61 |
| Rate for Payer: IEHP Medi-Cal |
$31,556.61
|
|
