|
DESMOPRESSIN 25 MCG 1/4 TAB [4080522]
|
Facility
IP
|
$3.02
|
|
|
Service Code
|
NDC 9994-0805-22
|
| Hospital Charge Code |
1712429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.15
|
| Rate for Payer: Blue Shield of California EPN |
$1.55
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Cigna of CA HMO |
$2.11
|
| Rate for Payer: Cigna of CA PPO |
$2.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Galaxy Health WC |
$2.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$1.96
|
| Rate for Payer: Prime Health Services Commercial |
$2.57
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
IP
|
$61.20
|
|
|
Service Code
|
CPT J2597
|
| Hospital Charge Code |
1757507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$52.02 |
| Rate for Payer: Blue Shield of California Commercial |
$43.57
|
| Rate for Payer: Blue Shield of California Commercial |
$44.86
|
| Rate for Payer: Blue Shield of California EPN |
$31.33
|
| Rate for Payer: Blue Shield of California EPN |
$32.26
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$27.54
|
| Rate for Payer: Cigna of CA HMO |
$42.84
|
| Rate for Payer: Cigna of CA HMO |
$44.10
|
| Rate for Payer: Cigna of CA PPO |
$42.84
|
| Rate for Payer: Cigna of CA PPO |
$44.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$25.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.48
|
| Rate for Payer: Galaxy Health WC |
$52.02
|
| Rate for Payer: Galaxy Health WC |
$53.55
|
| Rate for Payer: Global Benefits Group Commercial |
$36.72
|
| Rate for Payer: Global Benefits Group Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.69
|
| Rate for Payer: Multiplan Commercial |
$48.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Networks By Design Commercial |
$31.50
|
| Rate for Payer: Networks By Design Commercial |
$30.60
|
| Rate for Payer: Prime Health Services Commercial |
$52.02
|
| Rate for Payer: Prime Health Services Commercial |
$53.55
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
OP
|
$63.00
|
|
|
Service Code
|
CPT J2597
|
| Hospital Charge Code |
1720511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Networks By Design Commercial |
$31.50
|
| Rate for Payer: Networks By Design Commercial |
$34.80
|
| Rate for Payer: Networks By Design Commercial |
$35.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$39.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$39.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$39.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.79
|
| Rate for Payer: BCBS Transplant Transplant |
$41.76
|
| Rate for Payer: BCBS Transplant Transplant |
$42.85
|
| Rate for Payer: BCBS Transplant Transplant |
$37.80
|
| Rate for Payer: Blue Shield of California Commercial |
$46.43
|
| Rate for Payer: Blue Shield of California Commercial |
$51.30
|
| Rate for Payer: Blue Shield of California Commercial |
$52.64
|
| Rate for Payer: Blue Shield of California EPN |
$16.30
|
| Rate for Payer: Blue Shield of California EPN |
$16.30
|
| Rate for Payer: Blue Shield of California EPN |
$16.30
|
| Rate for Payer: Cash Price |
$31.32
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$32.14
|
| Rate for Payer: Cash Price |
$32.14
|
| Rate for Payer: Cash Price |
$31.32
|
| Rate for Payer: Cigna of CA HMO |
$44.10
|
| Rate for Payer: Cigna of CA HMO |
$49.99
|
| Rate for Payer: Cigna of CA HMO |
$48.72
|
| Rate for Payer: Cigna of CA PPO |
$48.72
|
| Rate for Payer: Cigna of CA PPO |
$44.10
|
| Rate for Payer: Cigna of CA PPO |
$49.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Media |
$6.33
|
| Rate for Payer: Dignity Health Media |
$6.33
|
| Rate for Payer: Dignity Health Media |
$6.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.33
|
| Rate for Payer: Galaxy Health WC |
$60.71
|
| Rate for Payer: Galaxy Health WC |
$53.55
|
| Rate for Payer: Galaxy Health WC |
$59.16
|
| Rate for Payer: Global Benefits Group Commercial |
$41.76
|
| Rate for Payer: Global Benefits Group Commercial |
$42.85
|
| Rate for Payer: Global Benefits Group Commercial |
$37.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$53.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$47.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$52.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Transplant |
$10.38
|
| Rate for Payer: Heritage Provider Network Transplant |
$10.38
|
| Rate for Payer: Heritage Provider Network Transplant |
$10.38
|
| Rate for Payer: IEHP Medi-Cal |
$10.25
|
| Rate for Payer: IEHP Medi-Cal |
$10.25
|
| Rate for Payer: IEHP Medi-Cal |
$10.25
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$10.25
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$10.25
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$10.25
|
| Rate for Payer: IEHP Medicare Advantage |
$6.33
|
| Rate for Payer: IEHP Medicare Advantage |
$6.33
|
| Rate for Payer: IEHP Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$46.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$47.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$57.14
|
| Rate for Payer: Multiplan Commercial |
$55.68
|
| Rate for Payer: Prime Health Services Commercial |
$60.71
|
| Rate for Payer: Prime Health Services Commercial |
$53.55
|
| Rate for Payer: Prime Health Services Commercial |
$59.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$37.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$42.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$41.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$37.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$41.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$42.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$34.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO |
$35.71
|
| Rate for Payer: United Healthcare All Other HMO |
$34.80
|
| Rate for Payer: United Healthcare HMO Rider |
$34.80
|
| Rate for Payer: United Healthcare HMO Rider |
$35.71
|
| Rate for Payer: United Healthcare HMO Rider |
$31.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
IP
|
$63.00
|
|
|
Service Code
|
CPT J2597
|
| Hospital Charge Code |
1720511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Blue Shield of California Commercial |
$44.86
|
| Rate for Payer: Blue Shield of California Commercial |
$50.85
|
| Rate for Payer: Blue Shield of California Commercial |
$49.56
|
| Rate for Payer: Blue Shield of California EPN |
$32.26
|
| Rate for Payer: Blue Shield of California EPN |
$36.57
|
| Rate for Payer: Blue Shield of California EPN |
$35.64
|
| Rate for Payer: Cash Price |
$31.32
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$32.14
|
| Rate for Payer: Cigna of CA HMO |
$44.10
|
| Rate for Payer: Cigna of CA HMO |
$49.99
|
| Rate for Payer: Cigna of CA HMO |
$48.72
|
| Rate for Payer: Cigna of CA PPO |
$49.99
|
| Rate for Payer: Cigna of CA PPO |
$44.10
|
| Rate for Payer: Cigna of CA PPO |
$48.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$27.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$25.20
|
| Rate for Payer: Galaxy Health WC |
$59.16
|
| Rate for Payer: Galaxy Health WC |
$60.71
|
| Rate for Payer: Galaxy Health WC |
$53.55
|
| Rate for Payer: Global Benefits Group Commercial |
$37.80
|
| Rate for Payer: Global Benefits Group Commercial |
$42.85
|
| Rate for Payer: Global Benefits Group Commercial |
$41.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$47.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$46.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.70
|
| Rate for Payer: Multiplan Commercial |
$57.14
|
| Rate for Payer: Multiplan Commercial |
$55.68
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Networks By Design Commercial |
$34.80
|
| Rate for Payer: Networks By Design Commercial |
$31.50
|
| Rate for Payer: Networks By Design Commercial |
$35.71
|
| Rate for Payer: Prime Health Services Commercial |
$59.16
|
| Rate for Payer: Prime Health Services Commercial |
$53.55
|
| Rate for Payer: Prime Health Services Commercial |
$60.71
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
OP
|
$61.20
|
|
|
Service Code
|
CPT J2597
|
| Hospital Charge Code |
1757507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$52.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$39.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$39.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.79
|
| Rate for Payer: BCBS Transplant Transplant |
$36.72
|
| Rate for Payer: BCBS Transplant Transplant |
$37.80
|
| Rate for Payer: Blue Shield of California Commercial |
$45.10
|
| Rate for Payer: Blue Shield of California Commercial |
$46.43
|
| Rate for Payer: Blue Shield of California EPN |
$16.30
|
| Rate for Payer: Blue Shield of California EPN |
$16.30
|
| Rate for Payer: Cash Price |
$27.54
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$27.54
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cigna of CA HMO |
$44.10
|
| Rate for Payer: Cigna of CA HMO |
$42.84
|
| Rate for Payer: Cigna of CA PPO |
$44.10
|
| Rate for Payer: Cigna of CA PPO |
$42.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Media |
$6.33
|
| Rate for Payer: Dignity Health Media |
$6.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.33
|
| Rate for Payer: Galaxy Health WC |
$53.55
|
| Rate for Payer: Galaxy Health WC |
$52.02
|
| Rate for Payer: Global Benefits Group Commercial |
$36.72
|
| Rate for Payer: Global Benefits Group Commercial |
$37.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$45.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$47.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Transplant |
$10.38
|
| Rate for Payer: Heritage Provider Network Transplant |
$10.38
|
| Rate for Payer: IEHP Medi-Cal |
$10.25
|
| Rate for Payer: IEHP Medi-Cal |
$10.25
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$10.25
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$10.25
|
| Rate for Payer: IEHP Medicare Advantage |
$6.33
|
| Rate for Payer: IEHP Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$48.96
|
| Rate for Payer: Networks By Design Commercial |
$30.60
|
| Rate for Payer: Networks By Design Commercial |
$31.50
|
| Rate for Payer: Prime Health Services Commercial |
$53.55
|
| Rate for Payer: Prime Health Services Commercial |
$52.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$37.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$37.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO |
$30.60
|
| Rate for Payer: United Healthcare HMO Rider |
$31.50
|
| Rate for Payer: United Healthcare HMO Rider |
$30.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
|
|
DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 9994-0804-00
|
| Hospital Charge Code |
1715267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 9994-0804-00
|
| Hospital Charge Code |
1715267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: BCBS Transplant Transplant |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-1
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-3
|
| Hospital Charge Code |
1743247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: BCBS Transplant Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Media |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0168-0309-15
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: BCBS Transplant Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Media |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-1
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: BCBS Transplant Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Media |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0168-0309-15
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-3
|
| Hospital Charge Code |
1743247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
OP
|
$3.29
|
|
|
Service Code
|
NDC 45802-495-35
|
| Hospital Charge Code |
1743316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.96
|
| Rate for Payer: BCBS Transplant Transplant |
$1.97
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$2.30
|
| Rate for Payer: Cigna of CA PPO |
$2.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.80
|
| Rate for Payer: Dignity Health Media |
$2.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$2.80
|
| Rate for Payer: Global Benefits Group Commercial |
$1.97
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
| Rate for Payer: Networks By Design Commercial |
$2.14
|
| Rate for Payer: Prime Health Services Commercial |
$2.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other HMO |
$1.64
|
| Rate for Payer: United Healthcare HMO Rider |
$1.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: Vantage Medical Group Senior |
$2.80
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
IP
|
$3.29
|
|
|
Service Code
|
NDC 45802-495-35
|
| Hospital Charge Code |
1743316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Blue Shield of California Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California EPN |
$1.68
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$2.30
|
| Rate for Payer: Cigna of CA PPO |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$2.80
|
| Rate for Payer: Global Benefits Group Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
| Rate for Payer: Networks By Design Commercial |
$2.14
|
| Rate for Payer: Prime Health Services Commercial |
$2.80
|
|
|
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
|
Facility
OP
|
$4,984.00
|
|
|
Service Code
|
CPT 17106
|
| Min. Negotiated Rate |
$498.20 |
| Max. Negotiated Rate |
$4,984.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Media |
$498.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$672.57
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$498.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$817.05
|
| Rate for Payer: Heritage Provider Network Transplant |
$817.05
|
| Rate for Payer: IEHP Medi-Cal |
$807.08
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$807.08
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$601.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$498.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$667.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-30
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.44
|
| Rate for Payer: BCBS Transplant Transplant |
$10.51
|
| Rate for Payer: Blue Shield of California Commercial |
$12.91
|
| Rate for Payer: Blue Shield of California EPN |
$10.23
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cigna of CA HMO |
$12.26
|
| Rate for Payer: Cigna of CA PPO |
$12.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.89
|
| Rate for Payer: Dignity Health Media |
$14.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.01
|
| Rate for Payer: Galaxy Health WC |
$14.89
|
| Rate for Payer: Global Benefits Group Commercial |
$10.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$14.02
|
| Rate for Payer: Networks By Design Commercial |
$11.39
|
| Rate for Payer: Prime Health Services Commercial |
$14.89
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$10.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Other HMO |
$8.76
|
| Rate for Payer: United Healthcare HMO Rider |
$8.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.89
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-13
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$13.95
|
|
|
Service Code
|
NDC 0008-1211-50
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Blue Shield of California Commercial |
$9.93
|
| Rate for Payer: Blue Shield of California EPN |
$7.14
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cigna of CA HMO |
$9.76
|
| Rate for Payer: Cigna of CA PPO |
$9.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.58
|
| Rate for Payer: Galaxy Health WC |
$11.86
|
| Rate for Payer: Global Benefits Group Commercial |
$8.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$11.16
|
| Rate for Payer: Networks By Design Commercial |
$9.07
|
| Rate for Payer: Prime Health Services Commercial |
$11.86
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-14
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Cigna of CA HMO |
$12.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.44
|
| Rate for Payer: BCBS Transplant Transplant |
$10.51
|
| Rate for Payer: Blue Shield of California Commercial |
$12.91
|
| Rate for Payer: Blue Shield of California EPN |
$10.23
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$12.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.89
|
| Rate for Payer: Dignity Health Media |
$14.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.01
|
| Rate for Payer: Galaxy Health WC |
$14.89
|
| Rate for Payer: Global Benefits Group Commercial |
$10.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$14.02
|
| Rate for Payer: Networks By Design Commercial |
$11.39
|
| Rate for Payer: Prime Health Services Commercial |
$14.89
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$10.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Other HMO |
$8.76
|
| Rate for Payer: United Healthcare HMO Rider |
$8.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.89
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-22
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: BCBS Transplant Transplant |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Media |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-13
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: BCBS Transplant Transplant |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Media |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-14
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Blue Shield of California Commercial |
$12.47
|
| Rate for Payer: Blue Shield of California EPN |
$8.97
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cigna of CA HMO |
$12.26
|
| Rate for Payer: Cigna of CA PPO |
$12.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.01
|
| Rate for Payer: Galaxy Health WC |
$14.89
|
| Rate for Payer: Global Benefits Group Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$14.02
|
| Rate for Payer: Networks By Design Commercial |
$11.39
|
| Rate for Payer: Prime Health Services Commercial |
$14.89
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$13.95
|
|
|
Service Code
|
NDC 0008-1211-50
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.31
|
| Rate for Payer: BCBS Transplant Transplant |
$8.37
|
| Rate for Payer: Blue Shield of California Commercial |
$10.28
|
| Rate for Payer: Blue Shield of California EPN |
$8.15
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cigna of CA HMO |
$9.76
|
| Rate for Payer: Cigna of CA PPO |
$9.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.86
|
| Rate for Payer: Dignity Health Media |
$11.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.58
|
| Rate for Payer: Galaxy Health WC |
$11.86
|
| Rate for Payer: Global Benefits Group Commercial |
$8.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$11.16
|
| Rate for Payer: Networks By Design Commercial |
$9.07
|
| Rate for Payer: Prime Health Services Commercial |
$11.86
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$8.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO |
$6.98
|
| Rate for Payer: United Healthcare HMO Rider |
$6.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.86
|
| Rate for Payer: Vantage Medical Group Senior |
$11.86
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-22
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
|
