|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
ERX4080265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| 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 Media |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| 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 |
ERX4080265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| 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: 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: 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
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.34
|
| Rate for Payer: BCBS Transplant Transplant |
$3.37
|
| Rate for Payer: Blue Shield of California Commercial |
$4.13
|
| Rate for Payer: Blue Shield of California EPN |
$3.28
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Media |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.80
|
| Rate for Payer: United Healthcare All Other HMO |
$2.80
|
| Rate for Payer: United Healthcare HMO Rider |
$2.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
IP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
IP
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Blue Shield of California Commercial |
$3.99
|
| Rate for Payer: Blue Shield of California EPN |
$2.87
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
OP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: BCBS Transplant Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Media |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
OP
|
$6.63
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
1710229
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.95
|
| Rate for Payer: BCBS Transplant Transplant |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$4.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.87
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cigna of CA HMO |
$4.64
|
| Rate for Payer: Cigna of CA PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.64
|
| Rate for Payer: Dignity Health Media |
$5.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.65
|
| Rate for Payer: Galaxy Health WC |
$5.64
|
| Rate for Payer: Global Benefits Group Commercial |
$3.98
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$5.30
|
| Rate for Payer: Networks By Design Commercial |
$4.31
|
| Rate for Payer: Prime Health Services Commercial |
$5.64
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.64
|
| Rate for Payer: Vantage Medical Group Senior |
$5.64
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
IP
|
$6.63
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
1710229
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Blue Shield of California Commercial |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$3.39
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cigna of CA HMO |
$4.64
|
| Rate for Payer: Cigna of CA PPO |
$4.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.65
|
| Rate for Payer: Galaxy Health WC |
$5.64
|
| Rate for Payer: Global Benefits Group Commercial |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$5.30
|
| Rate for Payer: Networks By Design Commercial |
$4.31
|
| Rate for Payer: Prime Health Services Commercial |
$5.64
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$10,023.60
|
|
|
Service Code
|
APR-DRG 2841
|
| Min. Negotiated Rate |
$7,689.16 |
| Max. Negotiated Rate |
$10,023.60 |
| Rate for Payer: IEHP Medi-Cal |
$7,689.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,023.60
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$13,238.88
|
|
|
Service Code
|
APR-DRG 2842
|
| Min. Negotiated Rate |
$10,155.61 |
| Max. Negotiated Rate |
$13,238.88 |
| Rate for Payer: IEHP Medi-Cal |
$10,155.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,238.88
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$18,337.58
|
|
|
Service Code
|
APR-DRG 2843
|
| Min. Negotiated Rate |
$14,066.86 |
| Max. Negotiated Rate |
$18,337.58 |
| Rate for Payer: IEHP Medi-Cal |
$14,066.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,337.58
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
IP
|
$31,822.97
|
|
|
Service Code
|
APR-DRG 2844
|
| Min. Negotiated Rate |
$24,411.57 |
| Max. Negotiated Rate |
$31,822.97 |
| Rate for Payer: IEHP Medi-Cal |
$24,411.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,822.97
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$8,282.06
|
|
|
Service Code
|
APR-DRG 2821
|
| Min. Negotiated Rate |
$6,353.21 |
| Max. Negotiated Rate |
$8,282.06 |
| Rate for Payer: IEHP Medi-Cal |
$6,353.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,282.06
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$36,352.38
|
|
|
Service Code
|
APR-DRG 2824
|
| Min. Negotiated Rate |
$27,886.10 |
| Max. Negotiated Rate |
$36,352.38 |
| Rate for Payer: IEHP Medi-Cal |
$27,886.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,352.38
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$10,784.42
|
|
|
Service Code
|
APR-DRG 2822
|
| Min. Negotiated Rate |
$8,272.78 |
| Max. Negotiated Rate |
$10,784.42 |
| Rate for Payer: IEHP Medi-Cal |
$8,272.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,784.42
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
IP
|
$16,416.91
|
|
|
Service Code
|
APR-DRG 2823
|
| Min. Negotiated Rate |
$12,593.50 |
| Max. Negotiated Rate |
$16,416.91 |
| Rate for Payer: IEHP Medi-Cal |
$12,593.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,416.91
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
IP
|
$4,579.08
|
|
|
Service Code
|
APR-DRG 7521
|
| Min. Negotiated Rate |
$3,512.63 |
| Max. Negotiated Rate |
$4,579.08 |
| Rate for Payer: IEHP Medi-Cal |
$3,512.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,579.08
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
IP
|
$14,787.11
|
|
|
Service Code
|
APR-DRG 7523
|
| Min. Negotiated Rate |
$11,343.27 |
| Max. Negotiated Rate |
$14,787.11 |
| Rate for Payer: IEHP Medi-Cal |
$11,343.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,787.11
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
IP
|
$58,538.37
|
|
|
Service Code
|
APR-DRG 7524
|
| Min. Negotiated Rate |
$44,905.09 |
| Max. Negotiated Rate |
$58,538.37 |
| Rate for Payer: IEHP Medi-Cal |
$44,905.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58,538.37
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
IP
|
$6,450.08
|
|
|
Service Code
|
APR-DRG 7522
|
| Min. Negotiated Rate |
$4,947.89 |
| Max. Negotiated Rate |
$6,450.08 |
| Rate for Payer: IEHP Medi-Cal |
$4,947.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,450.08
|
|
|
DISULFIRAM 250 MG TABLET [2540]
|
Facility
OP
|
$3.92
|
|
|
Service Code
|
NDC 0093-5035-01
|
| Hospital Charge Code |
1710473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.34
|
| Rate for Payer: BCBS Transplant Transplant |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$2.29
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO |
$2.74
|
| Rate for Payer: Cigna of CA PPO |
$2.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.33
|
| Rate for Payer: Dignity Health Media |
$3.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.57
|
| Rate for Payer: Galaxy Health WC |
$3.33
|
| Rate for Payer: Global Benefits Group Commercial |
$2.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$3.14
|
| Rate for Payer: Networks By Design Commercial |
$2.55
|
| Rate for Payer: Prime Health Services Commercial |
$3.33
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.96
|
| Rate for Payer: United Healthcare All Other HMO |
$1.96
|
| Rate for Payer: United Healthcare HMO Rider |
$1.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.33
|
| Rate for Payer: Vantage Medical Group Senior |
$3.33
|
|
|
DISULFIRAM 250 MG TABLET [2540]
|
Facility
OP
|
$2.39
|
|
|
Service Code
|
NDC 64980-171-01
|
| Hospital Charge Code |
1710473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: BCBS Transplant Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Media |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
DISULFIRAM 250 MG TABLET [2540]
|
Facility
IP
|
$2.39
|
|
|
Service Code
|
NDC 64980-171-01
|
| Hospital Charge Code |
1710473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
|
|
DISULFIRAM 250 MG TABLET [2540]
|
Facility
IP
|
$3.92
|
|
|
Service Code
|
NDC 0093-5035-01
|
| Hospital Charge Code |
1710473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Blue Shield of California Commercial |
$2.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO |
$2.74
|
| Rate for Payer: Cigna of CA PPO |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Galaxy Health WC |
$3.33
|
| Rate for Payer: Global Benefits Group Commercial |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$3.14
|
| Rate for Payer: Networks By Design Commercial |
$2.55
|
| Rate for Payer: Prime Health Services Commercial |
$3.33
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
IP
|
$1.01
|
|
|
Service Code
|
NDC 68084-313-11
|
| Hospital Charge Code |
1711540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.86
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.86
|
|
