|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [2417]
|
Facility
|
OP
|
$50.44
|
|
|
Service Code
|
CPT J0500
|
| Hospital Charge Code |
1720318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.74 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$30.26
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$30.26
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Cash Price |
$22.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$30.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$37.83
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [2417]
|
Facility
|
IP
|
$50.44
|
|
|
Service Code
|
CPT J0500
|
| Hospital Charge Code |
1720318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.74 |
| Max. Negotiated Rate |
$40.35 |
| Rate for Payer: Cash Price |
$22.70
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$37.83
|
|
|
DICYCLOMINE 20 MG TABLET [2420]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 60687-380-01
|
| Hospital Charge Code |
1711317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
|
DICYCLOMINE 20 MG TABLET [2420]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0591-0795-01
|
| Hospital Charge Code |
1711317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
|
DICYCLOMINE 20 MG TABLET [2420]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 60687-380-11
|
| Hospital Charge Code |
1711317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
|
DICYCLOMINE 20 MG TABLET [2420]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 60687-380-11
|
| Hospital Charge Code |
1711317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
|
DICYCLOMINE 20 MG TABLET [2420]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 60687-380-01
|
| Hospital Charge Code |
1711317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
|
DICYCLOMINE 20 MG TABLET [2420]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0591-0795-01
|
| Hospital Charge Code |
1711317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
|
DIFLUPREDNATE 0.05 % EYE DROPS [92859]
|
Facility
|
OP
|
$52.32
|
|
|
Service Code
|
NDC 0065-9240-07
|
| Hospital Charge Code |
NDG92859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$39.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$31.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$31.39
|
| Rate for Payer: Cash Price |
$23.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$31.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$39.24
|
|
|
DIFLUPREDNATE 0.05 % EYE DROPS [92859]
|
Facility
|
IP
|
$52.32
|
|
|
Service Code
|
NDC 0065-9240-07
|
| Hospital Charge Code |
NDG92859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$41.86 |
| Rate for Payer: Cash Price |
$23.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$39.24
|
|
|
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION [9853]
|
Facility
|
OP
|
$151.63
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
1720393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$113.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$90.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$90.98
|
| Rate for Payer: Cash Price |
$68.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$90.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$90.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$113.72
|
|
|
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION [9853]
|
Facility
|
IP
|
$151.63
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
1720393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$121.30 |
| Rate for Payer: Cash Price |
$68.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$121.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$90.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$113.72
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 68084-366-11
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.30
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 0143-1240-01
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.06
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 0143-1240-01
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.85
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.06
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 68084-366-01
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.30
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 68084-366-01
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.30
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 0904-5921-61
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 0904-5921-61
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [2444]
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 68084-366-11
|
| Hospital Charge Code |
1710290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.30
|
|
|
DIGOXIN 250 MCG (0.25 MG) TABLET [2445]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 0904-5922-61
|
| Hospital Charge Code |
1710304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
DIGOXIN 250 MCG (0.25 MG) TABLET [2445]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 0904-5922-61
|
| Hospital Charge Code |
1710304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
DIGOXIN 250 MCG (0.25 MG) TABLET [2445]
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 60687-551-11
|
| Hospital Charge Code |
1710304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.04
|
|
|
DIGOXIN 250 MCG (0.25 MG) TABLET [2445]
|
Facility
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 60687-551-11
|
| Hospital Charge Code |
1710304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.83
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.04
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [110919]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
1720137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cash Price |
$34.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$56.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.48
|
|
