|
DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 68094-750-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
|
|
DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 68094-750-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 68094-750-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
|
|
DIAZEPAM 5 MG/5 ML (1 MG/ML) ORAL SOLUTION [2402]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0054-3188-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
DIAZEPAM 5 MG/5 ML (1 MG/ML) ORAL SOLUTION [2402]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0054-3188-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]
|
Facility
|
OP
|
$14.76
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$26.76 |
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.76
|
| Rate for Payer: Blue Shield of California Commercial |
$11.47
|
| Rate for Payer: Blue Shield of California Commercial |
$11.47
|
| Rate for Payer: Blue Shield of California EPN |
$11.47
|
| Rate for Payer: Blue Shield of California EPN |
$11.47
|
| Rate for Payer: Cash Price |
$8.12
|
| Rate for Payer: Cash Price |
$8.12
|
| Rate for Payer: Cash Price |
$8.12
|
| Rate for Payer: Cash Price |
$8.12
|
| Rate for Payer: Cigna of CA HMO |
$10.34
|
| Rate for Payer: Cigna of CA HMO |
$10.33
|
| Rate for Payer: Cigna of CA PPO |
$10.33
|
| Rate for Payer: Cigna of CA PPO |
$10.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.91
|
| Rate for Payer: EPIC Health Plan Senior |
$5.91
|
| Rate for Payer: EPIC Health Plan Senior |
$5.90
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.34
|
| Rate for Payer: Multiplan Commercial |
$11.82
|
| Rate for Payer: Multiplan Commercial |
$11.81
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO |
$5.39
|
| Rate for Payer: United Healthcare All Other HMO |
$5.40
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.55
|
| Rate for Payer: Vantage Medical Group Senior |
$12.55
|
| Rate for Payer: Vantage Medical Group Senior |
$12.55
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]
|
Facility
|
IP
|
$14.77
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$10.90
|
| Rate for Payer: Blue Shield of California Commercial |
$10.89
|
| Rate for Payer: Blue Shield of California EPN |
$7.17
|
| Rate for Payer: Blue Shield of California EPN |
$7.18
|
| Rate for Payer: Cash Price |
$8.12
|
| Rate for Payer: Cash Price |
$8.12
|
| Rate for Payer: Cigna of CA HMO |
$10.34
|
| Rate for Payer: Cigna of CA HMO |
$10.33
|
| Rate for Payer: Cigna of CA PPO |
$10.33
|
| Rate for Payer: Cigna of CA PPO |
$10.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.91
|
| Rate for Payer: EPIC Health Plan Senior |
$5.90
|
| Rate for Payer: EPIC Health Plan Senior |
$5.91
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$11.81
|
| Rate for Payer: Multiplan Commercial |
$11.82
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.39
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.84
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 51079-285-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 51079-285-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]
|
Facility
|
IP
|
$12.38
|
|
|
Service Code
|
NDC 13517-100-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: EPIC Health Plan Commercial |
$4.95
|
| Rate for Payer: EPIC Health Plan Senior |
$4.95
|
| Rate for Payer: Galaxy Health WC |
$10.52
|
| Rate for Payer: Cigna of CA HMO |
$8.67
|
| Rate for Payer: Cigna of CA PPO |
$8.67
|
| Rate for Payer: Adventist Health Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California Commercial |
$9.14
|
| Rate for Payer: Blue Shield of California EPN |
$6.02
|
| Rate for Payer: Cash Price |
$6.81
|
| Rate for Payer: Global Benefits Group Commercial |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.05
|
| Rate for Payer: Prime Health Services Commercial |
$10.52
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]
|
Facility
|
OP
|
$12.38
|
|
|
Service Code
|
NDC 13517-100-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Adventist Health Commercial |
$2.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.60
|
| Rate for Payer: Cash Price |
$6.81
|
| Rate for Payer: Cigna of CA HMO |
$8.67
|
| Rate for Payer: Cigna of CA PPO |
$8.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.95
|
| Rate for Payer: EPIC Health Plan Senior |
$4.95
|
| Rate for Payer: Galaxy Health WC |
$10.52
|
| Rate for Payer: Global Benefits Group Commercial |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.67
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.05
|
| Rate for Payer: Prime Health Services Commercial |
$10.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.19
|
| Rate for Payer: United Healthcare All Other HMO |
$6.19
|
| Rate for Payer: United Healthcare HMO Rider |
$6.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.52
|
| Rate for Payer: Vantage Medical Group Senior |
$10.52
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 24208-457-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 61314-014-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 61314-014-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.06
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 24208-457-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.06
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 69097-524-44
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 0536-1294-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 43598-977-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0067-8152-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0067-8152-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 45802-953-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0067-8152-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0067-8152-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
