|
Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 64645
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$951.00 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
|
|
Chemodenervation of parotid and submandibular salivary glands, bilateral
|
Facility
OP
|
$5,779.00
|
|
|
Service Code
|
CPT 64611
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$370.06 |
| Max. Negotiated Rate |
$5,779.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$370.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$951.13
|
| Rate for Payer: Blue Shield of California EPN |
$683.14
|
| Rate for Payer: Caremore Medicare Advantage |
$370.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$499.58
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$370.06
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$606.90
|
| Rate for Payer: IEHP medi-cal |
$610.60
|
| Rate for Payer: IEHP Medicare Advantage |
$370.06
|
| Rate for Payer: Innovage PACE Commercial |
$555.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$370.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$495.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$495.88
|
| Rate for Payer: Prime Health Services Medicare |
$392.26
|
| Rate for Payer: Riverside University Health MISP |
$407.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
Chemodenervation of trunk muscle(s); 1-5 muscle(s)
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 64646
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$864.04 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$864.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$864.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,166.45
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$864.04
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,417.03
|
| Rate for Payer: IEHP medi-cal |
$1,425.67
|
| Rate for Payer: IEHP Medicare Advantage |
$864.04
|
| Rate for Payer: Innovage PACE Commercial |
$1,296.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$864.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,157.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,157.81
|
| Rate for Payer: Prime Health Services Medicare |
$915.88
|
| Rate for Payer: Riverside University Health MISP |
$950.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
CHEMOTHERAPY FOR ACUTE LEUKEMIA
|
Facility
IP
|
$19,103.11
|
|
|
Service Code
|
APR-DRG 6953
|
| Min. Negotiated Rate |
$16,030.58 |
| Max. Negotiated Rate |
$19,103.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,030.58
|
| Rate for Payer: IEHP medi-cal |
$19,103.11
|
|
|
CHEMOTHERAPY FOR ACUTE LEUKEMIA
|
Facility
IP
|
$59,274.11
|
|
|
Service Code
|
APR-DRG 6954
|
| Min. Negotiated Rate |
$49,740.52 |
| Max. Negotiated Rate |
$59,274.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$49,740.52
|
| Rate for Payer: IEHP medi-cal |
$59,274.11
|
|
|
CHEMOTHERAPY FOR ACUTE LEUKEMIA
|
Facility
IP
|
$6,596.39
|
|
|
Service Code
|
APR-DRG 6951
|
| Min. Negotiated Rate |
$5,535.43 |
| Max. Negotiated Rate |
$6,596.39 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,535.43
|
| Rate for Payer: IEHP medi-cal |
$6,596.39
|
|
|
CHEMOTHERAPY FOR ACUTE LEUKEMIA
|
Facility
IP
|
$9,135.11
|
|
|
Service Code
|
APR-DRG 6952
|
| Min. Negotiated Rate |
$7,665.83 |
| Max. Negotiated Rate |
$9,135.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,665.83
|
| Rate for Payer: IEHP medi-cal |
$9,135.11
|
|
|
CHERRY FLAVOR (BULK) ORAL LIQUID [1562]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 395266216
|
| Hospital Charge Code |
NDG1562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
CHERRY FLAVOR (BULK) ORAL LIQUID [1562]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 395266216
|
| Hospital Charge Code |
NDG1562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
CHEST PAIN
|
Facility
IP
|
$5,658.05
|
|
|
Service Code
|
APR-DRG 2031
|
| Min. Negotiated Rate |
$4,748.02 |
| Max. Negotiated Rate |
$5,658.05 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,748.02
|
| Rate for Payer: IEHP medi-cal |
$5,658.05
|
|
|
CHEST PAIN
|
Facility
IP
|
$12,387.93
|
|
|
Service Code
|
APR-DRG 2034
|
| Min. Negotiated Rate |
$10,395.47 |
| Max. Negotiated Rate |
$12,387.93 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,395.47
|
| Rate for Payer: IEHP medi-cal |
$12,387.93
|
|
|
CHEST PAIN
|
Facility
IP
|
$8,340.93
|
|
|
Service Code
|
APR-DRG 2033
|
| Min. Negotiated Rate |
$6,999.38 |
| Max. Negotiated Rate |
$8,340.93 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,999.38
|
| Rate for Payer: IEHP medi-cal |
$8,340.93
|
|
|
CHEST PAIN
|
Facility
IP
|
$6,691.16
|
|
|
Service Code
|
APR-DRG 2032
|
| Min. Negotiated Rate |
$5,614.96 |
| Max. Negotiated Rate |
$6,691.16 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,614.96
|
| Rate for Payer: IEHP medi-cal |
$6,691.16
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
IP
|
$32,613.58
|
|
|
Service Code
|
APR-DRG 0111
|
| Min. Negotiated Rate |
$27,368.04 |
| Max. Negotiated Rate |
$32,613.58 |
| Rate for Payer: Adventist Health Medi-Cal |
$27,368.04
|
| Rate for Payer: IEHP medi-cal |
$32,613.58
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
IP
|
$48,390.46
|
|
|
Service Code
|
APR-DRG 0112
|
| Min. Negotiated Rate |
$40,607.38 |
| Max. Negotiated Rate |
$48,390.46 |
| Rate for Payer: Adventist Health Medi-Cal |
$40,607.38
|
| Rate for Payer: IEHP medi-cal |
$48,390.46
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
IP
|
$185,595.98
|
|
|
Service Code
|
APR-DRG 0114
|
| Min. Negotiated Rate |
$155,744.88 |
| Max. Negotiated Rate |
$185,595.98 |
| Rate for Payer: Adventist Health Medi-Cal |
$155,744.88
|
| Rate for Payer: IEHP medi-cal |
$185,595.98
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
IP
|
$91,355.12
|
|
|
Service Code
|
APR-DRG 0113
|
| Min. Negotiated Rate |
$76,661.64 |
| Max. Negotiated Rate |
$91,355.12 |
| Rate for Payer: Adventist Health Medi-Cal |
$76,661.64
|
| Rate for Payer: IEHP medi-cal |
$91,355.12
|
|
|
CHLORAMPHENICOL SODIUM SUCCINATE 1 GRAM INTRAVENOUS SOLUTION [25518]
|
Facility
IP
|
$58.38
|
|
|
Service Code
|
CPT J0720
|
| Hospital Charge Code |
ERX25518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.68 |
| Max. Negotiated Rate |
$52.54 |
| Rate for Payer: Blue Shield of California Commercial |
$43.78
|
| Rate for Payer: Blue Shield of California EPN |
$31.17
|
| Rate for Payer: Cash Price |
$26.27
|
| Rate for Payer: Central Health Plan Commercial |
$46.70
|
| Rate for Payer: Cigna of CA HMO |
$40.87
|
| Rate for Payer: Cigna of CA PPO |
$40.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.35
|
| Rate for Payer: Galaxy Health WC |
$49.62
|
| Rate for Payer: Global Benefits Group Commercial |
$35.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$52.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$38.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.68
|
| Rate for Payer: Multiplan Commercial |
$43.78
|
| Rate for Payer: Networks By Design Commercial |
$29.19
|
| Rate for Payer: Prime Health Services Commercial |
$49.62
|
|
|
CHLORAMPHENICOL SODIUM SUCCINATE 1 GRAM INTRAVENOUS SOLUTION [25518]
|
Facility
OP
|
$58.38
|
|
|
Service Code
|
CPT J0720
|
| Hospital Charge Code |
ERX25518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.52 |
| Max. Negotiated Rate |
$297.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$297.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.52
|
| Rate for Payer: BCBS Transplant Transplant |
$35.03
|
| Rate for Payer: Blue Shield of California Commercial |
$51.37
|
| Rate for Payer: Blue Shield of California EPN |
$46.70
|
| Rate for Payer: Cash Price |
$26.27
|
| Rate for Payer: Cash Price |
$26.27
|
| Rate for Payer: Central Health Plan Commercial |
$46.70
|
| Rate for Payer: Cigna of CA HMO |
$40.87
|
| Rate for Payer: Cigna of CA PPO |
$40.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.35
|
| Rate for Payer: Galaxy Health WC |
$49.62
|
| Rate for Payer: Global Benefits Group Commercial |
$35.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$52.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$43.78
|
| Rate for Payer: IEHP medi-cal |
$20.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$38.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.68
|
| Rate for Payer: Multiplan Commercial |
$43.78
|
| Rate for Payer: Networks By Design Commercial |
$29.19
|
| Rate for Payer: Prime Health Services Commercial |
$49.62
|
| Rate for Payer: Riverside University Health MISP |
$23.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.19
|
| Rate for Payer: United Healthcare All Other HMO |
$29.19
|
| Rate for Payer: United Healthcare HMO Rider |
$29.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.62
|
| Rate for Payer: Vantage Medical Group Senior |
$49.62
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 0555-0033-05
|
| Hospital Charge Code |
1730119
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.09
|
| Rate for Payer: IEHP medi-cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: Riverside University Health MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 0555-0033-02
|
| Hospital Charge Code |
1730119
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 0555-0033-05
|
| Hospital Charge Code |
1730119
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 0555-0033-02
|
| Hospital Charge Code |
1730119
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 51079-141-20
|
| Hospital Charge Code |
1730120
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.48
|
| Rate for Payer: IEHP medi-cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: Riverside University Health MISP |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 0555-0159-02
|
| Hospital Charge Code |
1730120
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| 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: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
