|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 60687-217-11
|
| Hospital Charge Code |
1711534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 60687-217-11
|
| Hospital Charge Code |
1711534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 60687-217-01
|
| Hospital Charge Code |
1711534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 63304-721-90
|
| Hospital Charge Code |
1711535
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.71
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 50742-251-30
|
| Hospital Charge Code |
1711535
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.55
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 63304-721-90
|
| Hospital Charge Code |
1711535
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.71
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 50742-251-30
|
| Hospital Charge Code |
1711535
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.55
|
|
|
DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]
|
Facility
|
OP
|
$5.87
|
|
|
Service Code
|
NDC 47335-679-81
|
| Hospital Charge Code |
1712302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.52
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.40
|
|
|
DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 50742-252-90
|
| Hospital Charge Code |
1712302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]
|
Facility
|
IP
|
$5.87
|
|
|
Service Code
|
NDC 47335-679-81
|
| Hospital Charge Code |
1712302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.40
|
|
|
DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 50742-252-90
|
| Hospital Charge Code |
1712302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
DILTIAZEM ER 240 MG CAPSULE,24 HR,EXTENDED RELEASE [29273]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 68682-369-90
|
| Hospital Charge Code |
ERX29273
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.77
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.77
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.96
|
|
|
DILTIAZEM ER 240 MG CAPSULE,24 HR,EXTENDED RELEASE [29273]
|
Facility
|
IP
|
$1.28
|
|
|
Service Code
|
NDC 68682-369-90
|
| Hospital Charge Code |
ERX29273
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.96
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 51079-924-01
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 0378-6060-01
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.29
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 68462-850-01
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.49
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
OP
|
$3.05
|
|
|
Service Code
|
NDC 0378-6060-01
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.83
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.29
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 68462-850-01
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.49
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 51079-924-20
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 51079-924-01
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 51079-924-20
|
| Hospital Charge Code |
1711469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$3.79
|
|
|
Service Code
|
NDC 68462-851-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.84
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 0378-6090-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.61
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-20
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.50
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.80
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.50
|
|
