|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 62559-490-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 59762-1061-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 59762-1061-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 0406-1236-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0406-1236-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| 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 |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 62559-490-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
OP
|
$67.54
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.51 |
| Max. Negotiated Rate |
$79.37 |
| Rate for Payer: Adventist Health Commercial |
$13.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$44.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.37
|
| Rate for Payer: Blue Shield of California Commercial |
$31.77
|
| Rate for Payer: Blue Shield of California EPN |
$31.77
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna of CA HMO |
$47.28
|
| Rate for Payer: Cigna of CA PPO |
$47.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$57.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.02
|
| Rate for Payer: EPIC Health Plan Senior |
$27.02
|
| Rate for Payer: Galaxy Health WC |
$57.41
|
| Rate for Payer: Global Benefits Group Commercial |
$40.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$54.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$45.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.28
|
| Rate for Payer: Multiplan Commercial |
$54.03
|
| Rate for Payer: Networks By Design Commercial |
$33.77
|
| Rate for Payer: Prime Health Services Commercial |
$57.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$40.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$40.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.35
|
| Rate for Payer: United Healthcare All Other HMO |
$24.67
|
| Rate for Payer: United Healthcare HMO Rider |
$24.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.41
|
| Rate for Payer: Vantage Medical Group Senior |
$57.41
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
IP
|
$67.54
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.51 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Adventist Health Commercial |
$13.51
|
| Rate for Payer: Blue Shield of California Commercial |
$49.84
|
| Rate for Payer: Blue Shield of California EPN |
$32.82
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna of CA HMO |
$47.28
|
| Rate for Payer: Cigna of CA PPO |
$47.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.02
|
| Rate for Payer: EPIC Health Plan Senior |
$27.02
|
| Rate for Payer: Galaxy Health WC |
$57.41
|
| Rate for Payer: Global Benefits Group Commercial |
$40.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$45.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.21
|
| Rate for Payer: Multiplan Commercial |
$54.03
|
| Rate for Payer: Networks By Design Commercial |
$33.77
|
| Rate for Payer: Prime Health Services Commercial |
$57.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.35
|
| Rate for Payer: United Healthcare All Other HMO |
$24.67
|
| Rate for Payer: United Healthcare HMO Rider |
$24.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.12
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
IP
|
$65.62
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$55.78 |
| Rate for Payer: Adventist Health Commercial |
$13.12
|
| Rate for Payer: Blue Shield of California Commercial |
$48.43
|
| Rate for Payer: Blue Shield of California EPN |
$31.89
|
| Rate for Payer: Cash Price |
$36.09
|
| Rate for Payer: Cigna of CA HMO |
$45.93
|
| Rate for Payer: Cigna of CA PPO |
$45.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.25
|
| Rate for Payer: EPIC Health Plan Senior |
$26.25
|
| Rate for Payer: Galaxy Health WC |
$55.78
|
| Rate for Payer: Global Benefits Group Commercial |
$39.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$43.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.75
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
| Rate for Payer: Networks By Design Commercial |
$32.81
|
| Rate for Payer: Prime Health Services Commercial |
$55.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.63
|
| Rate for Payer: United Healthcare All Other HMO |
$23.97
|
| Rate for Payer: United Healthcare HMO Rider |
$23.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.49
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
OP
|
$65.62
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$79.37 |
| Rate for Payer: Adventist Health Commercial |
$13.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$43.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.37
|
| Rate for Payer: Blue Shield of California Commercial |
$31.77
|
| Rate for Payer: Blue Shield of California EPN |
$31.77
|
| Rate for Payer: Cash Price |
$36.09
|
| Rate for Payer: Cash Price |
$36.09
|
| Rate for Payer: Cigna of CA HMO |
$45.93
|
| Rate for Payer: Cigna of CA PPO |
$45.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$55.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$55.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.25
|
| Rate for Payer: EPIC Health Plan Senior |
$26.25
|
| Rate for Payer: Galaxy Health WC |
$55.78
|
| Rate for Payer: Global Benefits Group Commercial |
$39.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$54.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$43.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$45.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
| Rate for Payer: Networks By Design Commercial |
$32.81
|
| Rate for Payer: Prime Health Services Commercial |
$55.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$39.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$39.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.63
|
| Rate for Payer: United Healthcare All Other HMO |
$23.97
|
| Rate for Payer: United Healthcare HMO Rider |
$23.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$55.78
|
| Rate for Payer: Vantage Medical Group Senior |
$55.78
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
IP
|
$112.68
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$95.78 |
| Rate for Payer: Adventist Health Commercial |
$22.54
|
| Rate for Payer: Blue Shield of California Commercial |
$83.16
|
| Rate for Payer: Blue Shield of California EPN |
$54.76
|
| Rate for Payer: Cash Price |
$61.97
|
| Rate for Payer: Cigna of CA HMO |
$78.88
|
| Rate for Payer: Cigna of CA PPO |
$78.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.07
|
| Rate for Payer: EPIC Health Plan Senior |
$45.07
|
| Rate for Payer: Galaxy Health WC |
$95.78
|
| Rate for Payer: Global Benefits Group Commercial |
$67.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$75.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$69.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.04
|
| Rate for Payer: Multiplan Commercial |
$90.14
|
| Rate for Payer: Networks By Design Commercial |
$56.34
|
| Rate for Payer: Prime Health Services Commercial |
$95.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.29
|
| Rate for Payer: United Healthcare All Other HMO |
$41.16
|
| Rate for Payer: United Healthcare HMO Rider |
$40.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.90
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
OP
|
$112.68
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$127.76 |
| Rate for Payer: Adventist Health Commercial |
$22.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$73.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.76
|
| Rate for Payer: Blue Shield of California Commercial |
$55.04
|
| Rate for Payer: Blue Shield of California EPN |
$55.04
|
| Rate for Payer: Cash Price |
$61.97
|
| Rate for Payer: Cash Price |
$61.97
|
| Rate for Payer: Cigna of CA HMO |
$78.88
|
| Rate for Payer: Cigna of CA PPO |
$78.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.07
|
| Rate for Payer: EPIC Health Plan Senior |
$45.07
|
| Rate for Payer: Galaxy Health WC |
$95.78
|
| Rate for Payer: Global Benefits Group Commercial |
$67.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$75.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$69.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.88
|
| Rate for Payer: Multiplan Commercial |
$90.14
|
| Rate for Payer: Networks By Design Commercial |
$56.34
|
| Rate for Payer: Prime Health Services Commercial |
$95.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$67.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$67.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.29
|
| Rate for Payer: United Healthcare All Other HMO |
$41.16
|
| Rate for Payer: United Healthcare HMO Rider |
$40.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.78
|
| Rate for Payer: Vantage Medical Group Senior |
$95.78
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
OP
|
$111.59
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.32 |
| Max. Negotiated Rate |
$127.76 |
| Rate for Payer: EPIC Health Plan Commercial |
$44.64
|
| Rate for Payer: EPIC Health Plan Senior |
$44.64
|
| Rate for Payer: Galaxy Health WC |
$94.85
|
| Rate for Payer: Global Benefits Group Commercial |
$66.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$74.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$69.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.11
|
| Rate for Payer: Multiplan Commercial |
$89.27
|
| Rate for Payer: Networks By Design Commercial |
$55.80
|
| Rate for Payer: Prime Health Services Commercial |
$94.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$66.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$66.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.88
|
| Rate for Payer: United Healthcare All Other HMO |
$40.76
|
| Rate for Payer: United Healthcare HMO Rider |
$39.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$94.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.85
|
| Rate for Payer: Vantage Medical Group Senior |
$94.85
|
| Rate for Payer: Adventist Health Commercial |
$22.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$73.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$94.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$83.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.76
|
| Rate for Payer: Blue Shield of California Commercial |
$55.04
|
| Rate for Payer: Blue Shield of California EPN |
$55.04
|
| Rate for Payer: Cash Price |
$61.37
|
| Rate for Payer: Cash Price |
$61.37
|
| Rate for Payer: Cigna of CA HMO |
$78.11
|
| Rate for Payer: Cigna of CA PPO |
$78.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$94.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$94.85
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
IP
|
$111.59
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.32 |
| Max. Negotiated Rate |
$94.85 |
| Rate for Payer: Adventist Health Commercial |
$22.32
|
| Rate for Payer: Blue Shield of California Commercial |
$82.35
|
| Rate for Payer: Blue Shield of California EPN |
$54.23
|
| Rate for Payer: Cash Price |
$61.37
|
| Rate for Payer: Cigna of CA HMO |
$78.11
|
| Rate for Payer: Cigna of CA PPO |
$78.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.64
|
| Rate for Payer: EPIC Health Plan Senior |
$44.64
|
| Rate for Payer: Galaxy Health WC |
$94.85
|
| Rate for Payer: Global Benefits Group Commercial |
$66.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$74.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$69.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.78
|
| Rate for Payer: Multiplan Commercial |
$89.27
|
| Rate for Payer: Networks By Design Commercial |
$55.80
|
| Rate for Payer: Prime Health Services Commercial |
$94.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.88
|
| Rate for Payer: United Healthcare All Other HMO |
$40.76
|
| Rate for Payer: United Healthcare HMO Rider |
$39.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.55
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
OP
|
$139.57
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$324.43 |
| Rate for Payer: Adventist Health Commercial |
$27.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$91.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$118.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$76.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$104.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$324.43
|
| Rate for Payer: Blue Shield of California Commercial |
$136.68
|
| Rate for Payer: Blue Shield of California EPN |
$136.68
|
| Rate for Payer: Cash Price |
$76.77
|
| Rate for Payer: Cash Price |
$76.77
|
| Rate for Payer: Cigna of CA HMO |
$97.70
|
| Rate for Payer: Cigna of CA PPO |
$97.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$118.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$118.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.83
|
| Rate for Payer: EPIC Health Plan Senior |
$55.83
|
| Rate for Payer: Galaxy Health WC |
$118.63
|
| Rate for Payer: Global Benefits Group Commercial |
$83.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$202.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$229.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$97.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$97.70
|
| Rate for Payer: Multiplan Commercial |
$111.66
|
| Rate for Payer: Networks By Design Commercial |
$69.78
|
| Rate for Payer: Prime Health Services Commercial |
$118.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$83.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$83.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.38
|
| Rate for Payer: United Healthcare All Other HMO |
$50.98
|
| Rate for Payer: United Healthcare HMO Rider |
$49.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$118.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.63
|
| Rate for Payer: Vantage Medical Group Senior |
$118.63
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
IP
|
$139.57
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$118.63 |
| Rate for Payer: Adventist Health Commercial |
$27.91
|
| Rate for Payer: Blue Shield of California Commercial |
$103.00
|
| Rate for Payer: Blue Shield of California EPN |
$67.83
|
| Rate for Payer: Cash Price |
$76.77
|
| Rate for Payer: Cigna of CA HMO |
$97.70
|
| Rate for Payer: Cigna of CA PPO |
$97.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.83
|
| Rate for Payer: EPIC Health Plan Senior |
$55.83
|
| Rate for Payer: Galaxy Health WC |
$118.63
|
| Rate for Payer: Global Benefits Group Commercial |
$83.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.50
|
| Rate for Payer: Multiplan Commercial |
$111.66
|
| Rate for Payer: Networks By Design Commercial |
$69.78
|
| Rate for Payer: Prime Health Services Commercial |
$118.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.38
|
| Rate for Payer: United Healthcare All Other HMO |
$50.98
|
| Rate for Payer: United Healthcare HMO Rider |
$49.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.71
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| 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 |
$0.11
|
| 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
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| 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: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| 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 |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| 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
|
| 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 |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.88
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.53
|
| Rate for Payer: United Healthcare All Other HMO |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| 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 |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| 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 |
$0.04
|
| 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 |
$0.06
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.51
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.29
|
| Rate for Payer: EPIC Health Plan Senior |
$2.29
|
| Rate for Payer: Galaxy Health WC |
$4.86
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$4.58
|
| Rate for Payer: Networks By Design Commercial |
$3.72
|
| Rate for Payer: Prime Health Services Commercial |
$4.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.86
|
| Rate for Payer: United Healthcare HMO Rider |
$2.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
|
