|
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
|
|
|
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 0054-0057-46
|
| Hospital Charge Code |
1715678
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.10
|
|
|
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
NDC 0054-0057-46
|
| Hospital Charge Code |
1715678
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.68
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.10
|
|
|
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION [31432]
|
Facility
|
OP
|
$5,518.80
|
|
|
Service Code
|
CPT J1162
|
| Hospital Charge Code |
1712460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,035.34 |
| Max. Negotiated Rate |
$4,139.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3,311.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3,311.28
|
| Rate for Payer: Cash Price |
$2,483.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,311.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3,311.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,035.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4,139.10
|
|
|
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION [31432]
|
Facility
|
IP
|
$5,518.80
|
|
|
Service Code
|
CPT J1162
|
| Hospital Charge Code |
1712460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,035.34 |
| Max. Negotiated Rate |
$4,415.04 |
| Rate for Payer: Cash Price |
$2,483.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,415.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,311.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,035.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4,139.10
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION [9859]
|
Facility
|
OP
|
$101.05
|
|
|
Service Code
|
CPT J1110
|
| Hospital Charge Code |
1720065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.58 |
| Max. Negotiated Rate |
$75.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$60.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$60.63
|
| Rate for Payer: Cash Price |
$45.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$60.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.79
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION [9859]
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
CPT J1110
|
| Hospital Charge Code |
1720065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.58 |
| Max. Negotiated Rate |
$80.84 |
| Rate for Payer: Cash Price |
$45.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.79
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68682-006-10
|
| Hospital Charge Code |
1712032
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.75
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0093-0318-01
|
| Hospital Charge Code |
1712032
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68682-006-10
|
| Hospital Charge Code |
1712032
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.75
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0093-0318-01
|
| Hospital Charge Code |
1712032
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 0641-6014-01
|
| Hospital Charge Code |
1720793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 17478-937-10
|
| Hospital Charge Code |
1720793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 0641-6013-01
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.62
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 0641-6014-10
|
| Hospital Charge Code |
1720793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 70860-301-05
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 17478-937-05
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 17478-937-05
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 0641-6014-10
|
| Hospital Charge Code |
1720793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 70860-301-05
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 0641-6014-01
|
| Hospital Charge Code |
1720793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 70860-301-41
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 17478-937-10
|
| Hospital Charge Code |
1720793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 70860-301-41
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97253]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 0641-6013-01
|
| Hospital Charge Code |
1722001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.62
|
|
