|
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 |
$12.37 |
| Max. Negotiated Rate |
$55.66 |
| Rate for Payer: Blue Shield of California Commercial |
$46.39
|
| Rate for Payer: Blue Shield of California EPN |
$33.03
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Central Health Plan Commercial |
$49.48
|
| 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: Health Management Network EPO/PPO |
$55.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.37
|
| Rate for Payer: Multiplan Commercial |
$46.39
|
| Rate for Payer: Networks By Design Commercial |
$30.92
|
| Rate for Payer: Prime Health Services Commercial |
$52.57
|
|
|
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 |
$24.08 |
| Max. Negotiated Rate |
$235.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$235.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$81.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$89.10
|
| Rate for Payer: BCBS Transplant Transplant |
$72.23
|
| Rate for Payer: Blue Shield of California Commercial |
$49.07
|
| 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: Central Health Plan Commercial |
$96.30
|
| 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: 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 Management Network EPO/PPO |
$108.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.28
|
| Rate for Payer: IEHP medi-cal |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.08
|
| Rate for Payer: Multiplan Commercial |
$90.28
|
| Rate for Payer: Networks By Design Commercial |
$60.19
|
| Rate for Payer: Prime Health Services Commercial |
$102.32
|
| Rate for Payer: Riverside University Health MISP |
$48.15
|
| 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 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 |
$24.08 |
| Max. Negotiated Rate |
$108.34 |
| Rate for Payer: Blue Shield of California Commercial |
$90.28
|
| Rate for Payer: Blue Shield of California EPN |
$64.28
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Central Health Plan Commercial |
$96.30
|
| 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: Health Management Network EPO/PPO |
$108.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.08
|
| Rate for Payer: Multiplan Commercial |
$90.28
|
| Rate for Payer: Networks By Design Commercial |
$60.19
|
| Rate for Payer: Prime Health Services Commercial |
$102.32
|
|
|
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 |
$21.04 |
| Max. Negotiated Rate |
$235.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$235.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$89.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$57.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$81.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$89.10
|
| Rate for Payer: BCBS Transplant Transplant |
$63.11
|
| Rate for Payer: Blue Shield of California Commercial |
$49.07
|
| 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: Central Health Plan Commercial |
$84.15
|
| 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: 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 Management Network EPO/PPO |
$94.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$78.89
|
| Rate for Payer: IEHP medi-cal |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.04
|
| Rate for Payer: Multiplan Commercial |
$78.89
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$89.41
|
| Rate for Payer: Riverside University Health MISP |
$42.08
|
| 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 Medi-Cal |
$89.41
|
| Rate for Payer: Vantage Medical Group Senior |
$89.41
|
|
|
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 |
$21.04 |
| Max. Negotiated Rate |
$94.67 |
| Rate for Payer: Blue Shield of California Commercial |
$78.89
|
| Rate for Payer: Blue Shield of California EPN |
$56.17
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Central Health Plan Commercial |
$84.15
|
| 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: Health Management Network EPO/PPO |
$94.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.04
|
| Rate for Payer: Multiplan Commercial |
$78.89
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$89.41
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| 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: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| 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: 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 Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.08
|
| 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 Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
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 |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: BCBS Transplant Transplant |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| 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: 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 Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.30
|
| Rate for Payer: IEHP medi-cal |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: Riverside University Health MISP |
$1.22
|
| 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 Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
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 |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Blue Shield of California Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| 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: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$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 |
$0.01 |
| 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: Central Health Plan Commercial |
$0.06
|
| 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: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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 |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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 Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Riverside University Health MISP |
$0.03
|
| 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 Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
|
Facility
OP
|
$27,445.00
|
|
|
Service Code
|
CPT 63075
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$27,445.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,938.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,071.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,572.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,017.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$12,220.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$8,938.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,067.02
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$8,938.53
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$14,659.19
|
| Rate for Payer: IEHP medi-cal |
$14,748.57
|
| Rate for Payer: IEHP Medicare Advantage |
$8,938.53
|
| Rate for Payer: Innovage PACE Commercial |
$13,407.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,938.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,977.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,977.63
|
| Rate for Payer: Multiplan WC |
$12,220.24
|
| Rate for Payer: Preferred Health Network WC |
$12,469.63
|
| Rate for Payer: Prime Health Services Medicare |
$9,474.84
|
| Rate for Payer: Prime Health Services WC |
$12,095.54
|
| Rate for Payer: Riverside University Health MISP |
$9,832.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,813.00
|
| Rate for Payer: United Healthcare All Other HMO |
$27,445.00
|
| Rate for Payer: United Healthcare HMO Rider |
$17,214.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,742.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
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 |
$0.48 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: BCBS Transplant Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Central Health Plan Commercial |
$1.91
|
| 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: 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 Management Network EPO/PPO |
$2.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.79
|
| Rate for Payer: IEHP medi-cal |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: Riverside University Health MISP |
$0.96
|
| 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 Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
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 |
$0.48 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Central Health Plan Commercial |
$1.91
|
| 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: Health Management Network EPO/PPO |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| 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
OP
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.31
|
| Rate for Payer: BCBS Transplant Transplant |
$3.37
|
| Rate for Payer: Blue Shield of California Commercial |
$3.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.74
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$4.49
|
| 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: 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 Management Network EPO/PPO |
$5.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.21
|
| Rate for Payer: IEHP medi-cal |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.37
|
| Rate for Payer: Riverside University Health MISP |
$2.24
|
| 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 Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
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 |
$1.12 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Blue Shield of California Commercial |
$4.21
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$4.49
|
| 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: Health Management Network EPO/PPO |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| 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
OP
|
$6.63
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
1710229
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.92
|
| Rate for Payer: BCBS Transplant Transplant |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$4.17
|
| Rate for Payer: Blue Shield of California EPN |
$3.24
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Central Health Plan Commercial |
$5.30
|
| 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: 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 Management Network EPO/PPO |
$5.97
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.97
|
| Rate for Payer: IEHP medi-cal |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$4.97
|
| Rate for Payer: Networks By Design Commercial |
$4.31
|
| Rate for Payer: Prime Health Services Commercial |
$5.64
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.98
|
| Rate for Payer: Riverside University Health MISP |
$2.65
|
| 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 Medi-Cal |
$5.64
|
| Rate for Payer: Vantage Medical Group Senior |
$5.64
|
|
|
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 |
$1.33 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Blue Shield of California Commercial |
$4.97
|
| Rate for Payer: Blue Shield of California EPN |
$3.54
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Central Health Plan Commercial |
$5.30
|
| 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: Health Management Network EPO/PPO |
$5.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$4.97
|
| Rate for Payer: Networks By Design Commercial |
$4.31
|
| Rate for Payer: Prime Health Services Commercial |
$5.64
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$9,964.00
|
|
|
Service Code
|
APR-DRG 2842
|
| Min. Negotiated Rate |
$8,361.40 |
| Max. Negotiated Rate |
$9,964.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,361.40
|
| Rate for Payer: IEHP medi-cal |
$9,964.00
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$23,950.97
|
|
|
Service Code
|
APR-DRG 2844
|
| Min. Negotiated Rate |
$20,098.72 |
| Max. Negotiated Rate |
$23,950.97 |
| Rate for Payer: Adventist Health Medi-Cal |
$20,098.72
|
| Rate for Payer: IEHP medi-cal |
$23,950.97
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$13,801.44
|
|
|
Service Code
|
APR-DRG 2843
|
| Min. Negotiated Rate |
$11,581.63 |
| Max. Negotiated Rate |
$13,801.44 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,581.63
|
| Rate for Payer: IEHP medi-cal |
$13,801.44
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$7,544.08
|
|
|
Service Code
|
APR-DRG 2841
|
| Min. Negotiated Rate |
$6,330.70 |
| Max. Negotiated Rate |
$7,544.08 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,330.70
|
| Rate for Payer: IEHP medi-cal |
$7,544.08
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$8,116.69
|
|
|
Service Code
|
APR-DRG 2822
|
| Min. Negotiated Rate |
$6,811.21 |
| Max. Negotiated Rate |
$8,116.69 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,811.21
|
| Rate for Payer: IEHP medi-cal |
$8,116.69
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$6,233.34
|
|
|
Service Code
|
APR-DRG 2821
|
| Min. Negotiated Rate |
$5,230.78 |
| Max. Negotiated Rate |
$6,233.34 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,230.78
|
| Rate for Payer: IEHP medi-cal |
$6,233.34
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$27,359.95
|
|
|
Service Code
|
APR-DRG 2824
|
| Min. Negotiated Rate |
$22,959.40 |
| Max. Negotiated Rate |
$27,359.95 |
| Rate for Payer: Adventist Health Medi-Cal |
$22,959.40
|
| Rate for Payer: IEHP medi-cal |
$27,359.95
|
|
