|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 9999408186
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 9999408186
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 6050547541
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 7095415930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 7095415930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 5167240421
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 1310731901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 5167240421
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 1310731901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 6050547541
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 7095415940
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 7095415940
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 7095415950
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 7095415950
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
|
|
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 25605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$455.97 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,412.45
|
| Rate for Payer: EPIC Health Plan Senior |
$2,274.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,391.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$455.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$515.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,895.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,605.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: Prime Health Services WC |
$3,206.94
|
| Rate for Payer: United Healthcare All Other HMO |
$4,460.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,591.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,374.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,068.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 21453
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$566.66 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$566.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$640.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,593.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, WITH MANIPULATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 26705
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$342.13 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,412.45
|
| Rate for Payer: EPIC Health Plan Senior |
$2,274.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,391.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$342.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$386.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,895.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,605.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: Prime Health Services WC |
$3,206.94
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,068.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITHOUT STABILIZATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 21315
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$133.22 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,195.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,995.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,195.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,995.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,292.74
|
| Rate for Payer: EPIC Health Plan Senior |
$2,195.16
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,272.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$133.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,995.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$150.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,793.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,514.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,674.10
|
| Rate for Payer: Multiplan WC |
$2,998.82
|
| Rate for Payer: Prime Health Services WC |
$2,968.22
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,995.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,195.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1,995.60
|
|
|
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 21320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$212.65 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,264.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,690.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,264.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,035.98
|
| Rate for Payer: EPIC Health Plan Senior |
$4,690.65
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,993.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$212.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,264.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$240.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,969.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,372.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,714.07
|
| Rate for Payer: Multiplan WC |
$6,565.51
|
| Rate for Payer: Prime Health Services WC |
$6,498.52
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,264.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4,264.23
|
|
|
CLOSED TREATMENT OF PATELLAR FRACTURE, WITHOUT MANIPULATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$317.26 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$317.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$475.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$348.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$317.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$523.48
|
| Rate for Payer: EPIC Health Plan Senior |
$348.99
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$520.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$317.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$444.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$399.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$425.13
|
| Rate for Payer: Multiplan WC |
$485.64
|
| Rate for Payer: Prime Health Services WC |
$480.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$317.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Vantage Medical Group Senior |
$317.26
|
|
|
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 26725
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$227.67 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$317.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$899.51
|
| Rate for Payer: Blue Shield of California Commercial |
$594.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$475.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$348.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$317.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$523.48
|
| Rate for Payer: EPIC Health Plan Senior |
$348.99
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$520.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$227.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$317.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$257.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$444.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$399.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$425.13
|
| Rate for Payer: Multiplan WC |
$485.64
|
| Rate for Payer: Prime Health Services WC |
$480.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$317.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Vantage Medical Group Senior |
$317.26
|
|
|
CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITH MANIPULATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 23525
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$317.26 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$317.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$475.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$348.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$317.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$523.48
|
| Rate for Payer: EPIC Health Plan Senior |
$348.99
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$520.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$317.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$444.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$399.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$425.13
|
| Rate for Payer: Multiplan WC |
$485.64
|
| Rate for Payer: Prime Health Services WC |
$480.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$317.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Vantage Medical Group Senior |
$317.26
|
|
|
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 24535
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,412.45
|
| Rate for Payer: EPIC Health Plan Senior |
$2,274.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,391.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,895.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,605.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: Prime Health Services WC |
$3,206.94
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,068.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; WITHOUT MANIPULATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 24530
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$317.26 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$317.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$475.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$348.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$317.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$523.48
|
| Rate for Payer: EPIC Health Plan Senior |
$348.99
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$520.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$334.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$317.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$378.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$444.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$399.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$425.13
|
| Rate for Payer: Multiplan WC |
$485.64
|
| Rate for Payer: Prime Health Services WC |
$480.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$317.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$475.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$348.99
|
| Rate for Payer: Vantage Medical Group Senior |
$317.26
|
|
|
CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITH OR WITHOUT MANIPULATION, WITH SKELETAL TRACTION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27532
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$420.32 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$420.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$475.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,302.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: Prime Health Services WC |
$6,501.60
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
