|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994080265
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994080265
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA INVOLVING VISCERAL VESSELS (MESENTERIC, CELIAC, RENAL)
|
Facility
|
OP
|
$12,185.00
|
|
|
Service Code
|
CPT 35092
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,984.00 |
| Max. Negotiated Rate |
$12,185.00 |
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,185.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
NDC 0025275231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.68
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 0093312701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 0025275231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.86
|
| Rate for Payer: Blue Shield of California Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.54
|
| Rate for Payer: Heritage Provider Network Senior |
$3.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Senior |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 0093312701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
NDC 0093312901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.89
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2.29
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
NDC 0025276231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.07 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.35
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Senior |
$4.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
NDC 0025276231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.38
|
| Rate for Payer: Blue Shield of California Commercial |
$4.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.73
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Senior |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Vantage Medical Group Senior |
$5.75
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 0093312901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.74
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$15,524.24
|
|
|
Service Code
|
MSDRG 442
|
| Min. Negotiated Rate |
$11,585.25 |
| Max. Negotiated Rate |
$15,524.24 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,585.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,585.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,323.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,524.24
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$28,260.06
|
|
|
Service Code
|
MSDRG 441
|
| Min. Negotiated Rate |
$21,089.60 |
| Max. Negotiated Rate |
$28,260.06 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,089.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,089.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,253.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,260.06
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$11,445.84
|
|
|
Service Code
|
MSDRG 443
|
| Min. Negotiated Rate |
$8,541.67 |
| Max. Negotiated Rate |
$11,445.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,541.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,541.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,822.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,445.84
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC
|
Facility
|
IP
|
$13,618.62
|
|
|
Service Code
|
MSDRG 439
|
| Min. Negotiated Rate |
$10,163.15 |
| Max. Negotiated Rate |
$13,618.62 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,163.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,163.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,687.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,618.62
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$25,734.07
|
|
|
Service Code
|
MSDRG 438
|
| Min. Negotiated Rate |
$19,204.53 |
| Max. Negotiated Rate |
$25,734.07 |
| Rate for Payer: EPIC Health Plan Medicare |
$19,204.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19,204.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22,085.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,734.07
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$10,243.48
|
|
|
Service Code
|
MSDRG 440
|
| Min. Negotiated Rate |
$7,644.39 |
| Max. Negotiated Rate |
$10,243.48 |
| Rate for Payer: EPIC Health Plan Medicare |
$7,644.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,644.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,791.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,243.48
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
|
IP
|
$30,895.05
|
|
|
Service Code
|
MSDRG 883
|
| Min. Negotiated Rate |
$23,056.01 |
| Max. Negotiated Rate |
$30,895.05 |
| Rate for Payer: EPIC Health Plan Medicare |
$23,056.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$23,056.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,514.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,895.05
|
|
|
DISORDERS OF THE BILIARY TRACT WITH CC
|
Facility
|
IP
|
$17,506.63
|
|
|
Service Code
|
MSDRG 445
|
| Min. Negotiated Rate |
$13,064.65 |
| Max. Negotiated Rate |
$17,506.63 |
| Rate for Payer: EPIC Health Plan Medicare |
$13,064.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,064.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,024.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,506.63
|
|
|
DISORDERS OF THE BILIARY TRACT WITH MCC
|
Facility
|
IP
|
$26,359.05
|
|
|
Service Code
|
MSDRG 444
|
| Min. Negotiated Rate |
$19,670.93 |
| Max. Negotiated Rate |
$26,359.05 |
| Rate for Payer: EPIC Health Plan Medicare |
$19,670.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19,670.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22,621.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26,359.05
|
|
|
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC
|
Facility
|
IP
|
$13,405.16
|
|
|
Service Code
|
MSDRG 446
|
| Min. Negotiated Rate |
$10,003.85 |
| Max. Negotiated Rate |
$13,405.16 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,003.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,003.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,504.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,405.16
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
OP
|
$2.47
|
|
|
Service Code
|
NDC 0074611413
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$1.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.99
|
| Rate for Payer: TriValley Medical Group Senior |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.10
|
| Rate for Payer: Vantage Medical Group Senior |
$2.10
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 2724111501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 2724111501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 6808431311
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
