|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
OP
|
$80.39
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1721221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$205.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$205.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.56
|
| Rate for Payer: Blue Distinction Transplant |
$48.23
|
| Rate for Payer: Blue Shield of California Commercial |
$59.25
|
| Rate for Payer: Blue Shield of California EPN |
$30.01
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cigna of CA HMO |
$56.27
|
| Rate for Payer: Cigna of CA PPO |
$56.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.33
|
| Rate for Payer: Dignity Health Media |
$68.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.16
|
| Rate for Payer: Galaxy Health WC |
$68.33
|
| Rate for Payer: Global Benefits Group Commercial |
$48.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$60.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Commercial |
$64.31
|
| Rate for Payer: Networks By Design Commercial |
$40.20
|
| Rate for Payer: Prime Health Services Commercial |
$68.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.20
|
| Rate for Payer: United Healthcare All Other HMO |
$40.20
|
| Rate for Payer: United Healthcare HMO Rider |
$40.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.33
|
| Rate for Payer: Vantage Medical Group Senior |
$68.33
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
IP
|
$80.39
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1721221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$68.33 |
| Rate for Payer: Blue Shield of California Commercial |
$57.24
|
| Rate for Payer: Blue Shield of California EPN |
$41.16
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cigna of CA HMO |
$56.27
|
| Rate for Payer: Cigna of CA PPO |
$56.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.16
|
| Rate for Payer: Galaxy Health WC |
$68.33
|
| Rate for Payer: Global Benefits Group Commercial |
$48.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Commercial |
$64.31
|
| Rate for Payer: Networks By Design Commercial |
$40.20
|
| Rate for Payer: Prime Health Services Commercial |
$68.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.36
|
| Rate for Payer: United Healthcare All Other HMO |
$29.65
|
| Rate for Payer: United Healthcare HMO Rider |
$29.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26.53
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
OP
|
$61.85
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1712559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$205.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$205.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.56
|
| Rate for Payer: Blue Distinction Transplant |
$37.11
|
| Rate for Payer: Blue Shield of California Commercial |
$45.58
|
| Rate for Payer: Blue Shield of California EPN |
$30.01
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cigna of CA HMO |
$43.30
|
| Rate for Payer: Cigna of CA PPO |
$43.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.57
|
| Rate for Payer: Dignity Health Media |
$52.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.74
|
| Rate for Payer: Galaxy Health WC |
$52.57
|
| Rate for Payer: Global Benefits Group Commercial |
$37.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$46.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$49.48
|
| Rate for Payer: Networks By Design Commercial |
$30.92
|
| Rate for Payer: Prime Health Services Commercial |
$52.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$37.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$37.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.92
|
| Rate for Payer: United Healthcare All Other HMO |
$30.92
|
| Rate for Payer: United Healthcare HMO Rider |
$30.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.57
|
| Rate for Payer: Vantage Medical Group Senior |
$52.57
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
IP
|
$61.85
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1712559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$52.57 |
| Rate for Payer: Blue Shield of California Commercial |
$44.04
|
| Rate for Payer: Blue Shield of California EPN |
$31.67
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cigna of CA HMO |
$43.30
|
| Rate for Payer: Cigna of CA PPO |
$43.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.74
|
| Rate for Payer: Galaxy Health WC |
$52.57
|
| Rate for Payer: Global Benefits Group Commercial |
$37.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$49.48
|
| Rate for Payer: Networks By Design Commercial |
$30.92
|
| Rate for Payer: Prime Health Services Commercial |
$52.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.35
|
| Rate for Payer: United Healthcare All Other HMO |
$22.81
|
| Rate for Payer: United Healthcare HMO Rider |
$22.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.41
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
OP
|
$120.38
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
1726023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.89 |
| Max. Negotiated Rate |
$266.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$266.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$66.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.65
|
| Rate for Payer: Blue Distinction Transplant |
$72.23
|
| Rate for Payer: Blue Shield of California Commercial |
$88.72
|
| Rate for Payer: Blue Shield of California EPN |
$44.61
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cigna of CA HMO |
$84.27
|
| Rate for Payer: Cigna of CA PPO |
$84.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.32
|
| Rate for Payer: Dignity Health Media |
$102.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.15
|
| Rate for Payer: Galaxy Health WC |
$102.32
|
| Rate for Payer: Global Benefits Group Commercial |
$72.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$90.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.89
|
| Rate for Payer: Multiplan Commercial |
$96.30
|
| Rate for Payer: Networks By Design Commercial |
$60.19
|
| Rate for Payer: Prime Health Services Commercial |
$102.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.19
|
| Rate for Payer: United Healthcare All Other HMO |
$60.19
|
| Rate for Payer: United Healthcare HMO Rider |
$60.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.32
|
| Rate for Payer: Vantage Medical Group Senior |
$102.32
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
IP
|
$120.38
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
1726023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.89 |
| Max. Negotiated Rate |
$102.32 |
| Rate for Payer: Blue Shield of California Commercial |
$85.71
|
| Rate for Payer: Blue Shield of California EPN |
$61.63
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cigna of CA HMO |
$84.27
|
| Rate for Payer: Cigna of CA PPO |
$84.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.15
|
| Rate for Payer: Galaxy Health WC |
$102.32
|
| Rate for Payer: Global Benefits Group Commercial |
$72.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.89
|
| Rate for Payer: Multiplan Commercial |
$96.30
|
| Rate for Payer: Networks By Design Commercial |
$60.19
|
| Rate for Payer: Prime Health Services Commercial |
$102.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.46
|
| Rate for Payer: United Healthcare All Other HMO |
$44.40
|
| Rate for Payer: United Healthcare HMO Rider |
$43.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.73
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
IP
|
$105.19
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
ERX186294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.25 |
| Max. Negotiated Rate |
$89.41 |
| Rate for Payer: Blue Shield of California Commercial |
$74.90
|
| Rate for Payer: Blue Shield of California EPN |
$53.86
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna of CA HMO |
$73.63
|
| Rate for Payer: Cigna of CA PPO |
$73.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$42.08
|
| Rate for Payer: Galaxy Health WC |
$89.41
|
| Rate for Payer: Global Benefits Group Commercial |
$63.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$89.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.72
|
| Rate for Payer: United Healthcare All Other HMO |
$38.79
|
| Rate for Payer: United Healthcare HMO Rider |
$37.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.71
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
OP
|
$105.19
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
ERX186294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.25 |
| Max. Negotiated Rate |
$266.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$266.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.65
|
| Rate for Payer: Blue Distinction Transplant |
$63.11
|
| Rate for Payer: Blue Shield of California Commercial |
$77.53
|
| Rate for Payer: Blue Shield of California EPN |
$44.61
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna of CA HMO |
$73.63
|
| Rate for Payer: Cigna of CA PPO |
$73.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.41
|
| Rate for Payer: Dignity Health Media |
$89.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$42.08
|
| Rate for Payer: Galaxy Health WC |
$89.41
|
| Rate for Payer: Global Benefits Group Commercial |
$63.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$78.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$89.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.60
|
| Rate for Payer: United Healthcare All Other HMO |
$52.60
|
| Rate for Payer: United Healthcare HMO Rider |
$52.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.41
|
| Rate for Payer: Vantage Medical Group Senior |
$89.41
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
1710561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Media |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
1710561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
1710594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$1.57
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
1710594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.82
|
| Rate for Payer: Blue Distinction Transplant |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Media |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.53
|
| Rate for Payer: United Healthcare All Other HMO |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
ERX4080265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
ERX4080265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Distinction Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Media |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: Blue Distinction Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Media |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.34
|
| Rate for Payer: Blue Distinction Transplant |
$3.37
|
| Rate for Payer: Blue Shield of California Commercial |
$4.13
|
| Rate for Payer: Blue Shield of California EPN |
$3.28
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Media |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.80
|
| Rate for Payer: United Healthcare All Other HMO |
$2.80
|
| Rate for Payer: United Healthcare HMO Rider |
$2.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Blue Shield of California Commercial |
$3.99
|
| Rate for Payer: Blue Shield of California EPN |
$2.87
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
IP
|
$6.63
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
1710229
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Blue Shield of California Commercial |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$3.39
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cigna of CA HMO |
$4.64
|
| Rate for Payer: Cigna of CA PPO |
$4.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.65
|
| Rate for Payer: Galaxy Health WC |
$5.64
|
| Rate for Payer: Global Benefits Group Commercial |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$5.30
|
| Rate for Payer: Networks By Design Commercial |
$4.31
|
| Rate for Payer: Prime Health Services Commercial |
$5.64
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
OP
|
$6.63
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
1710229
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.95
|
| Rate for Payer: Blue Distinction Transplant |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$4.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.87
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cigna of CA HMO |
$4.64
|
| Rate for Payer: Cigna of CA PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.64
|
| Rate for Payer: Dignity Health Media |
$5.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.65
|
| Rate for Payer: Galaxy Health WC |
$5.64
|
| Rate for Payer: Global Benefits Group Commercial |
$3.98
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$5.30
|
| Rate for Payer: Networks By Design Commercial |
$4.31
|
| Rate for Payer: Prime Health Services Commercial |
$5.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.64
|
| Rate for Payer: Vantage Medical Group Senior |
$5.64
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$31,822.97
|
|
|
Service Code
|
APR-DRG 2844
|
| Min. Negotiated Rate |
$24,411.57 |
| Max. Negotiated Rate |
$31,822.97 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24,411.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,822.97
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$18,337.58
|
|
|
Service Code
|
APR-DRG 2843
|
| Min. Negotiated Rate |
$14,066.86 |
| Max. Negotiated Rate |
$18,337.58 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,066.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,337.58
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$10,023.60
|
|
|
Service Code
|
APR-DRG 2841
|
| Min. Negotiated Rate |
$7,689.16 |
| Max. Negotiated Rate |
$10,023.60 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,689.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,023.60
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$13,238.88
|
|
|
Service Code
|
APR-DRG 2842
|
| Min. Negotiated Rate |
$10,155.61 |
| Max. Negotiated Rate |
$13,238.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,155.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,238.88
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
|
IP
|
$36,352.38
|
|
|
Service Code
|
APR-DRG 2824
|
| Min. Negotiated Rate |
$27,886.10 |
| Max. Negotiated Rate |
$36,352.38 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,886.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,352.38
|
|
