|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$3.79
|
|
|
Service Code
|
NDC 68462-851-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.26
|
| Rate for Payer: Blue Distinction Transplant |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$2.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.21
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO |
$2.65
|
| Rate for Payer: Cigna of CA PPO |
$2.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.22
|
| Rate for Payer: Dignity Health Media |
$3.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.52
|
| Rate for Payer: Galaxy Health WC |
$3.22
|
| Rate for Payer: Global Benefits Group Commercial |
$2.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
| Rate for Payer: Networks By Design Commercial |
$2.46
|
| Rate for Payer: Prime Health Services Commercial |
$3.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.90
|
| Rate for Payer: United Healthcare All Other HMO |
$1.90
|
| Rate for Payer: United Healthcare HMO Rider |
$1.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.22
|
| Rate for Payer: Vantage Medical Group Senior |
$3.22
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 0378-6090-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cigna of CA HMO |
$2.44
|
| Rate for Payer: Cigna of CA PPO |
$2.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Galaxy Health WC |
$2.96
|
| Rate for Payer: Global Benefits Group Commercial |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.78
|
| Rate for Payer: Networks By Design Commercial |
$2.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.96
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-20
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Blue Shield of California Commercial |
$3.33
|
| Rate for Payer: Blue Shield of California EPN |
$2.39
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna of CA HMO |
$3.27
|
| Rate for Payer: Cigna of CA PPO |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.87
|
| Rate for Payer: Galaxy Health WC |
$3.97
|
| Rate for Payer: Global Benefits Group Commercial |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.74
|
| Rate for Payer: Networks By Design Commercial |
$3.04
|
| Rate for Payer: Prime Health Services Commercial |
$3.97
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
1715006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Distinction Transplant |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Media |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
1715006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-09
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Media |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-01
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Media |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-09
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-01
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
IP
|
$13.84
|
|
|
Service Code
|
CPT J1240
|
| Hospital Charge Code |
NDG2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Blue Shield of California Commercial |
$9.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna of CA HMO |
$9.69
|
| Rate for Payer: Cigna of CA PPO |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.54
|
| Rate for Payer: Galaxy Health WC |
$11.76
|
| Rate for Payer: Global Benefits Group Commercial |
$8.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: Networks By Design Commercial |
$6.92
|
| Rate for Payer: Prime Health Services Commercial |
$11.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.23
|
| Rate for Payer: United Healthcare All Other HMO |
$5.10
|
| Rate for Payer: United Healthcare HMO Rider |
$4.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.57
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
OP
|
$13.84
|
|
|
Service Code
|
CPT J1240
|
| Hospital Charge Code |
NDG2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$56.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$56.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.39
|
| Rate for Payer: Blue Distinction Transplant |
$8.30
|
| Rate for Payer: Blue Shield of California Commercial |
$10.20
|
| Rate for Payer: Blue Shield of California EPN |
$12.04
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna of CA HMO |
$9.69
|
| Rate for Payer: Cigna of CA PPO |
$9.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.76
|
| Rate for Payer: Dignity Health Media |
$11.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.54
|
| Rate for Payer: Galaxy Health WC |
$11.76
|
| Rate for Payer: Global Benefits Group Commercial |
$8.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: Networks By Design Commercial |
$6.92
|
| Rate for Payer: Prime Health Services Commercial |
$11.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.92
|
| Rate for Payer: United Healthcare All Other HMO |
$6.92
|
| Rate for Payer: United Healthcare HMO Rider |
$6.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.76
|
| Rate for Payer: Vantage Medical Group Senior |
$11.76
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
IP
|
$604.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1749027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.10 |
| Max. Negotiated Rate |
$513.91 |
| Rate for Payer: Blue Shield of California Commercial |
$430.48
|
| Rate for Payer: Blue Shield of California EPN |
$309.56
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Cigna of CA HMO |
$423.22
|
| Rate for Payer: Cigna of CA PPO |
$423.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$241.84
|
| Rate for Payer: Galaxy Health WC |
$513.91
|
| Rate for Payer: Global Benefits Group Commercial |
$362.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$403.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$230.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$145.10
|
| Rate for Payer: Multiplan Commercial |
$483.68
|
| Rate for Payer: Networks By Design Commercial |
$302.30
|
| Rate for Payer: Prime Health Services Commercial |
$513.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$228.30
|
| Rate for Payer: United Healthcare All Other HMO |
$222.98
|
| Rate for Payer: United Healthcare HMO Rider |
$218.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$199.52
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
OP
|
$604.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1749027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.10 |
| Max. Negotiated Rate |
$513.91 |
| Rate for Payer: Aetna of CA HMO/PPO |
$396.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$513.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$332.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$332.53
|
| Rate for Payer: Blue Distinction Transplant |
$362.76
|
| Rate for Payer: Blue Shield of California Commercial |
$445.59
|
| Rate for Payer: Blue Shield of California EPN |
$353.09
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Cigna of CA HMO |
$423.22
|
| Rate for Payer: Cigna of CA PPO |
$423.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$513.91
|
| Rate for Payer: Dignity Health Media |
$513.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$513.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$241.84
|
| Rate for Payer: Galaxy Health WC |
$513.91
|
| Rate for Payer: Global Benefits Group Commercial |
$362.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$453.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$403.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$145.10
|
| Rate for Payer: Multiplan Commercial |
$483.68
|
| Rate for Payer: Networks By Design Commercial |
$302.30
|
| Rate for Payer: Prime Health Services Commercial |
$513.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$362.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$362.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$302.30
|
| Rate for Payer: United Healthcare All Other HMO |
$302.30
|
| Rate for Payer: United Healthcare HMO Rider |
$302.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$302.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$513.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$513.91
|
| Rate for Payer: Vantage Medical Group Senior |
$513.91
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
|
OP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$908.36 |
| Max. Negotiated Rate |
$3,217.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,482.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,217.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,081.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,081.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,255.01
|
| Rate for Payer: Blue Distinction Transplant |
$2,270.91
|
| Rate for Payer: Blue Shield of California Commercial |
$2,789.43
|
| Rate for Payer: Blue Shield of California EPN |
$2,210.35
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Cigna of CA HMO |
$2,649.40
|
| Rate for Payer: Cigna of CA PPO |
$2,649.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,217.12
|
| Rate for Payer: Dignity Health Media |
$3,217.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,217.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,513.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,513.94
|
| Rate for Payer: Galaxy Health WC |
$3,217.12
|
| Rate for Payer: Global Benefits Group Commercial |
$2,270.91
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,838.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,524.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,442.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$908.36
|
| Rate for Payer: Multiplan Commercial |
$3,027.88
|
| Rate for Payer: Networks By Design Commercial |
$1,892.42
|
| Rate for Payer: Prime Health Services Commercial |
$3,217.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,270.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,270.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,892.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1,892.42
|
| Rate for Payer: United Healthcare HMO Rider |
$1,892.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,892.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,217.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,217.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3,217.12
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
|
IP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$908.36 |
| Max. Negotiated Rate |
$3,217.12 |
| Rate for Payer: Blue Shield of California Commercial |
$2,694.81
|
| Rate for Payer: Blue Shield of California EPN |
$1,937.84
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Cigna of CA HMO |
$2,649.40
|
| Rate for Payer: Cigna of CA PPO |
$2,649.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,513.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,513.94
|
| Rate for Payer: Galaxy Health WC |
$3,217.12
|
| Rate for Payer: Global Benefits Group Commercial |
$2,270.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,524.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,442.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$908.36
|
| Rate for Payer: Multiplan Commercial |
$3,027.88
|
| Rate for Payer: Networks By Design Commercial |
$1,892.42
|
| Rate for Payer: Prime Health Services Commercial |
$3,217.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,429.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1,395.85
|
| Rate for Payer: United Healthcare HMO Rider |
$1,365.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,249.00
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Distinction Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| 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 |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.68
|
| 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: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| 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 |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Distinction Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| 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 |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.68
|
| 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: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| 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 |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| 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 |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| 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: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| 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 |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| 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: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
