|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]
|
Facility
|
IP
|
$14.77
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$13.29 |
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$11.85
|
| Rate for Payer: Blue Shield of California Commercial |
$11.84
|
| Rate for Payer: Blue Shield of California EPN |
$7.44
|
| Rate for Payer: Blue Shield of California EPN |
$7.44
|
| Rate for Payer: Cash Price |
$6.65
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Central Health Plan Commercial |
$11.82
|
| Rate for Payer: Central Health Plan Commercial |
$11.81
|
| Rate for Payer: Cigna of CA HMO |
$10.33
|
| Rate for Payer: Cigna of CA HMO |
$10.34
|
| Rate for Payer: Cigna of CA PPO |
$10.33
|
| Rate for Payer: Cigna of CA PPO |
$10.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.91
|
| Rate for Payer: EPIC Health Plan Senior |
$5.90
|
| Rate for Payer: EPIC Health Plan Senior |
$5.91
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.95
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: Multiplan Commercial |
$11.08
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.39
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.84
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]
|
Facility
|
OP
|
$14.76
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$35.83 |
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$35.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$35.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.16
|
| Rate for Payer: Blue Shield of California Commercial |
$12.62
|
| Rate for Payer: Blue Shield of California Commercial |
$12.62
|
| Rate for Payer: Blue Shield of California EPN |
$11.47
|
| Rate for Payer: Blue Shield of California EPN |
$11.47
|
| Rate for Payer: Cash Price |
$6.65
|
| Rate for Payer: Cash Price |
$6.65
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Central Health Plan Commercial |
$11.81
|
| Rate for Payer: Central Health Plan Commercial |
$11.82
|
| Rate for Payer: Cigna of CA HMO |
$10.33
|
| Rate for Payer: Cigna of CA HMO |
$10.34
|
| Rate for Payer: Cigna of CA PPO |
$10.34
|
| Rate for Payer: Cigna of CA PPO |
$10.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.91
|
| Rate for Payer: EPIC Health Plan Senior |
$5.90
|
| Rate for Payer: EPIC Health Plan Senior |
$5.91
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Galaxy Health WC |
$12.55
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Global Benefits Group Commercial |
$8.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.34
|
| Rate for Payer: Multiplan Commercial |
$11.08
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: Prime Health Services Commercial |
$12.55
|
| Rate for Payer: Riverside University Health System MISP |
$5.91
|
| Rate for Payer: Riverside University Health System MISP |
$5.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.39
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare HMO Rider |
$5.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.55
|
| Rate for Payer: Vantage Medical Group Senior |
$12.55
|
| Rate for Payer: Vantage Medical Group Senior |
$12.55
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 5107928501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 5107928520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 5107928520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0378034501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 5107928501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0378034501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]
|
Facility
|
IP
|
$12.38
|
|
|
Service Code
|
NDC 1351710030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Adventist Health Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California Commercial |
$9.93
|
| Rate for Payer: Blue Shield of California EPN |
$6.24
|
| Rate for Payer: Cash Price |
$5.57
|
| Rate for Payer: Central Health Plan Commercial |
$9.90
|
| Rate for Payer: Cigna of CA HMO |
$8.67
|
| Rate for Payer: Cigna of CA PPO |
$8.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.95
|
| Rate for Payer: EPIC Health Plan Senior |
$4.95
|
| Rate for Payer: Galaxy Health WC |
$10.52
|
| Rate for Payer: Global Benefits Group Commercial |
$7.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$9.29
|
| Rate for Payer: Networks By Design Commercial |
$8.05
|
| Rate for Payer: Prime Health Services Commercial |
$10.52
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]
|
Facility
|
OP
|
$12.38
|
|
|
Service Code
|
NDC 1351710030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Adventist Health Commercial |
$2.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$7.85
|
| Rate for Payer: Blue Shield of California EPN |
$4.94
|
| Rate for Payer: Cash Price |
$5.57
|
| Rate for Payer: Central Health Plan Commercial |
$9.90
|
| Rate for Payer: Cigna of CA HMO |
$8.67
|
| Rate for Payer: Cigna of CA PPO |
$8.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.95
|
| Rate for Payer: EPIC Health Plan Senior |
$4.95
|
| Rate for Payer: Galaxy Health WC |
$10.52
|
| Rate for Payer: Global Benefits Group Commercial |
$7.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.67
|
| Rate for Payer: Multiplan Commercial |
$9.29
|
| Rate for Payer: Networks By Design Commercial |
$8.05
|
| Rate for Payer: Prime Health Services Commercial |
$10.52
|
| Rate for Payer: Riverside University Health System MISP |
$4.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.19
|
| Rate for Payer: United Healthcare All Other HMO |
$6.19
|
| Rate for Payer: United Healthcare HMO Rider |
$6.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.52
|
| Rate for Payer: Vantage Medical Group Senior |
$10.52
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 2420845705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Central Health Plan Commercial |
$2.69
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 2420845705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$2.13
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Central Health Plan Commercial |
$2.69
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
| Rate for Payer: Riverside University Health System MISP |
$1.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 6131401405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Central Health Plan Commercial |
$2.69
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 6131401405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$2.13
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Central Health Plan Commercial |
$2.69
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
| Rate for Payer: Riverside University Health System MISP |
$1.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 0536129434
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 4580295301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0067815202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| 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 Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.09
|
| 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
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 4359897710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 0067815202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| 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 |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 6909752444
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 4612275252
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 4612275252
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Riverside University Health System MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 6909752444
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 4359897710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 0536129434
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| 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
|
|
