|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 45802-358-03
|
| Hospital Charge Code |
1743710
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$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: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]
|
Facility
OP
|
$1.40
|
|
|
Service Code
|
NDC 0054-3194-46
|
| Hospital Charge Code |
1715914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: BCBS Transplant Transplant |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Media |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]
|
Facility
OP
|
$1.40
|
|
|
Service Code
|
NDC 9999-2515-01
|
| Hospital Charge Code |
NDG2515
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: BCBS Transplant Transplant |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Media |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]
|
Facility
IP
|
$1.40
|
|
|
Service Code
|
NDC 9999-2515-01
|
| Hospital Charge Code |
NDG2515
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]
|
Facility
IP
|
$1.40
|
|
|
Service Code
|
NDC 0054-3194-46
|
| Hospital Charge Code |
1715914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
OP
|
$0.56
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.33
|
| Rate for Payer: BCBS Transplant Transplant |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.25
|
| 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 Media |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.42
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.34
|
| 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
IP
|
$0.20
|
|
|
Service Code
|
NDC 62559-490-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: 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: 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
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 59762-1061-1
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: BCBS Transplant Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| 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 Media |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.37
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.29
|
| 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
OP
|
$0.20
|
|
|
Service Code
|
NDC 62559-490-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.15
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.12
|
| 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
IP
|
$0.49
|
|
|
Service Code
|
NDC 59762-1061-1
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| 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: 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: 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 |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: 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: 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
IP
|
$0.56
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.25
|
| 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: 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: 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
OP
|
$0.23
|
|
|
Service Code
|
NDC 0406-1236-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: BCBS Transplant Transplant |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.14
|
| 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
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
IP
|
$80.39
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1721221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$68.33 |
| Rate for Payer: Blue Shield of California Commercial |
$57.24
|
| Rate for Payer: Blue Shield of California EPN |
$41.16
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cigna of CA HMO |
$56.27
|
| Rate for Payer: Cigna of CA PPO |
$56.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.16
|
| Rate for Payer: Galaxy Health WC |
$68.33
|
| Rate for Payer: Global Benefits Group Commercial |
$48.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Commercial |
$64.31
|
| Rate for Payer: Networks By Design Commercial |
$40.20
|
| Rate for Payer: Prime Health Services Commercial |
$68.33
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
OP
|
$80.39
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1721221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$205.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$205.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.56
|
| Rate for Payer: BCBS Transplant Transplant |
$48.23
|
| Rate for Payer: Blue Shield of California Commercial |
$59.25
|
| Rate for Payer: Blue Shield of California EPN |
$30.01
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cigna of CA HMO |
$56.27
|
| Rate for Payer: Cigna of CA PPO |
$56.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.33
|
| Rate for Payer: Dignity Health Media |
$68.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.16
|
| Rate for Payer: Galaxy Health WC |
$68.33
|
| Rate for Payer: Global Benefits Group Commercial |
$48.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$60.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Commercial |
$64.31
|
| Rate for Payer: Networks By Design Commercial |
$40.20
|
| Rate for Payer: Prime Health Services Commercial |
$68.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.20
|
| Rate for Payer: United Healthcare All Other HMO |
$40.20
|
| Rate for Payer: United Healthcare HMO Rider |
$40.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.33
|
| Rate for Payer: Vantage Medical Group Senior |
$68.33
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
IP
|
$61.85
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1712559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$52.57 |
| Rate for Payer: Blue Shield of California Commercial |
$44.04
|
| Rate for Payer: Blue Shield of California EPN |
$31.67
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cigna of CA HMO |
$43.30
|
| Rate for Payer: Cigna of CA PPO |
$43.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.74
|
| Rate for Payer: Galaxy Health WC |
$52.57
|
| Rate for Payer: Global Benefits Group Commercial |
$37.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$49.48
|
| Rate for Payer: Networks By Design Commercial |
$30.92
|
| Rate for Payer: Prime Health Services Commercial |
$52.57
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
OP
|
$61.85
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1712559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$205.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$205.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$52.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$34.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$34.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.56
|
| Rate for Payer: BCBS Transplant Transplant |
$37.11
|
| Rate for Payer: Blue Shield of California Commercial |
$45.58
|
| Rate for Payer: Blue Shield of California EPN |
$30.01
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cigna of CA HMO |
$43.30
|
| Rate for Payer: Cigna of CA PPO |
$43.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.57
|
| Rate for Payer: Dignity Health Media |
$52.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.74
|
| Rate for Payer: Galaxy Health WC |
$52.57
|
| Rate for Payer: Global Benefits Group Commercial |
$37.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$46.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$49.48
|
| Rate for Payer: Networks By Design Commercial |
$30.92
|
| Rate for Payer: Prime Health Services Commercial |
$52.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$37.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$37.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.92
|
| Rate for Payer: United Healthcare All Other HMO |
$30.92
|
| Rate for Payer: United Healthcare HMO Rider |
$30.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.57
|
| Rate for Payer: Vantage Medical Group Senior |
$52.57
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
OP
|
$120.38
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
1726023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.89 |
| Max. Negotiated Rate |
$266.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$266.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.65
|
| Rate for Payer: BCBS Transplant Transplant |
$72.23
|
| Rate for Payer: Blue Shield of California Commercial |
$88.72
|
| Rate for Payer: Blue Shield of California EPN |
$44.61
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cigna of CA HMO |
$84.27
|
| Rate for Payer: Cigna of CA PPO |
$84.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.32
|
| Rate for Payer: Dignity Health Media |
$102.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.15
|
| Rate for Payer: Galaxy Health WC |
$102.32
|
| Rate for Payer: Global Benefits Group Commercial |
$72.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.89
|
| Rate for Payer: Multiplan Commercial |
$96.30
|
| Rate for Payer: Networks By Design Commercial |
$60.19
|
| Rate for Payer: Prime Health Services Commercial |
$102.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.19
|
| Rate for Payer: United Healthcare All Other HMO |
$60.19
|
| Rate for Payer: United Healthcare HMO Rider |
$60.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.32
|
| Rate for Payer: Vantage Medical Group Senior |
$102.32
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
IP
|
$120.38
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
1726023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.89 |
| Max. Negotiated Rate |
$102.32 |
| Rate for Payer: Blue Shield of California Commercial |
$85.71
|
| Rate for Payer: Blue Shield of California EPN |
$61.63
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cigna of CA HMO |
$84.27
|
| Rate for Payer: Cigna of CA PPO |
$84.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.15
|
| Rate for Payer: Galaxy Health WC |
$102.32
|
| Rate for Payer: Global Benefits Group Commercial |
$72.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.89
|
| Rate for Payer: Multiplan Commercial |
$96.30
|
| Rate for Payer: Networks By Design Commercial |
$60.19
|
| Rate for Payer: Prime Health Services Commercial |
$102.32
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
IP
|
$105.19
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
ERX186294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.25 |
| Max. Negotiated Rate |
$89.41 |
| Rate for Payer: Blue Shield of California Commercial |
$74.90
|
| Rate for Payer: Blue Shield of California EPN |
$53.86
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna of CA HMO |
$73.63
|
| Rate for Payer: Cigna of CA PPO |
$73.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$42.08
|
| Rate for Payer: Galaxy Health WC |
$89.41
|
| Rate for Payer: Global Benefits Group Commercial |
$63.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$89.41
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
OP
|
$105.19
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
ERX186294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.25 |
| Max. Negotiated Rate |
$266.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$266.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$89.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$57.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.65
|
| Rate for Payer: BCBS Transplant Transplant |
$63.11
|
| Rate for Payer: Blue Shield of California Commercial |
$77.53
|
| Rate for Payer: Blue Shield of California EPN |
$44.61
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna of CA HMO |
$73.63
|
| Rate for Payer: Cigna of CA PPO |
$73.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.41
|
| Rate for Payer: Dignity Health Media |
$89.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$42.08
|
| Rate for Payer: Galaxy Health WC |
$89.41
|
| Rate for Payer: Global Benefits Group Commercial |
$63.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$78.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$89.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.60
|
| Rate for Payer: United Healthcare All Other HMO |
$52.60
|
| Rate for Payer: United Healthcare HMO Rider |
$52.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.41
|
| Rate for Payer: Vantage Medical Group Senior |
$89.41
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
1710561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: 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: 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 |
1710561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 Media |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| 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
OP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
1710594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.82
|
| Rate for Payer: BCBS Transplant Transplant |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Cash Price |
$1.38
|
| 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 Media |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.30
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.84
|
| 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 75 MG TABLET [2530]
|
Facility
IP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
1710594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$1.57
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
|
