|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$3.74 |
| 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 51079-925-20
|
| 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
|
|
|
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
|
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 ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
1715006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.34
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
1715006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.34
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-09
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-09
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-01
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-01
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| 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 |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| 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 |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
IP
|
$13.84
|
|
|
Service Code
|
CPT J1240
|
| Hospital Charge Code |
NDG2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.61 |
| Max. Negotiated Rate |
$11.07 |
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.38
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
OP
|
$13.84
|
|
|
Service Code
|
CPT J1240
|
| Hospital Charge Code |
NDG2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.61 |
| Max. Negotiated Rate |
$10.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.30
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.38
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
IP
|
$604.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1749027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$332.53 |
| Max. Negotiated Rate |
$483.68 |
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$483.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$362.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$332.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$453.45
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
OP
|
$604.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1749027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$332.53 |
| Max. Negotiated Rate |
$453.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$362.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$362.76
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$362.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$362.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$332.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$453.45
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
|
OP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,081.67 |
| Max. Negotiated Rate |
$2,838.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,270.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,270.91
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,270.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2,270.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,081.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,838.64
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
|
IP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,081.67 |
| Max. Negotiated Rate |
$3,027.88 |
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,027.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,270.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,081.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,838.64
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
