|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 6255949001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA 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 |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| 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 |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| 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 5976210611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| 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 0406123601
|
| 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
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
IP
|
$70.25
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.05 |
| Max. Negotiated Rate |
$63.23 |
| Rate for Payer: Adventist Health Commercial |
$14.05
|
| Rate for Payer: Blue Shield of California Commercial |
$56.34
|
| Rate for Payer: Blue Shield of California EPN |
$35.41
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Central Health Plan Commercial |
$56.20
|
| Rate for Payer: Cigna of CA HMO |
$49.17
|
| Rate for Payer: Cigna of CA PPO |
$49.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$49.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.10
|
| Rate for Payer: EPIC Health Plan Senior |
$28.10
|
| Rate for Payer: Galaxy Health WC |
$59.71
|
| Rate for Payer: Global Benefits Group Commercial |
$42.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$63.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$44.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$41.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.05
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
| Rate for Payer: Networks By Design Commercial |
$35.12
|
| Rate for Payer: Prime Health Services Commercial |
$59.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$26.36
|
| Rate for Payer: United Healthcare All Other HMO |
$25.66
|
| Rate for Payer: United Healthcare HMO Rider |
$25.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.01
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
OP
|
$70.25
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.05 |
| Max. Negotiated Rate |
$191.43 |
| Rate for Payer: Adventist Health Commercial |
$14.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$191.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$38.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.16
|
| Rate for Payer: Blue Shield of California Commercial |
$34.95
|
| Rate for Payer: Blue Shield of California EPN |
$31.77
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Central Health Plan Commercial |
$56.20
|
| Rate for Payer: Cigna of CA HMO |
$49.17
|
| Rate for Payer: Cigna of CA PPO |
$49.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$59.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$49.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.10
|
| Rate for Payer: EPIC Health Plan Senior |
$28.10
|
| Rate for Payer: Galaxy Health WC |
$59.71
|
| Rate for Payer: Global Benefits Group Commercial |
$42.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$63.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$57.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$44.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$63.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$41.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49.17
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
| Rate for Payer: Networks By Design Commercial |
$35.12
|
| Rate for Payer: Prime Health Services Commercial |
$59.71
|
| Rate for Payer: Riverside University Health System MISP |
$28.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$42.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$42.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$26.36
|
| Rate for Payer: United Healthcare All Other HMO |
$25.66
|
| Rate for Payer: United Healthcare HMO Rider |
$25.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.71
|
| Rate for Payer: Vantage Medical Group Senior |
$59.71
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
IP
|
$68.24
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$61.42 |
| Rate for Payer: Adventist Health Commercial |
$13.65
|
| Rate for Payer: Blue Shield of California Commercial |
$54.73
|
| Rate for Payer: Blue Shield of California EPN |
$34.39
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Central Health Plan Commercial |
$54.59
|
| Rate for Payer: Cigna of CA HMO |
$47.77
|
| Rate for Payer: Cigna of CA PPO |
$47.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$47.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.30
|
| Rate for Payer: EPIC Health Plan Senior |
$27.30
|
| Rate for Payer: Galaxy Health WC |
$58.00
|
| Rate for Payer: Global Benefits Group Commercial |
$40.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$61.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$43.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.65
|
| Rate for Payer: Multiplan Commercial |
$51.18
|
| Rate for Payer: Networks By Design Commercial |
$34.12
|
| Rate for Payer: Prime Health Services Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.61
|
| Rate for Payer: United Healthcare All Other HMO |
$24.93
|
| Rate for Payer: United Healthcare HMO Rider |
$24.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.35
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
OP
|
$68.24
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$191.43 |
| Rate for Payer: Adventist Health Commercial |
$13.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$191.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$38.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.16
|
| Rate for Payer: Blue Shield of California Commercial |
$34.95
|
| Rate for Payer: Blue Shield of California EPN |
$31.77
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Central Health Plan Commercial |
$54.59
|
| Rate for Payer: Cigna of CA HMO |
$47.77
|
| Rate for Payer: Cigna of CA PPO |
$47.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$58.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$58.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$47.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.30
|
| Rate for Payer: EPIC Health Plan Senior |
$27.30
|
| Rate for Payer: Galaxy Health WC |
$58.00
|
| Rate for Payer: Global Benefits Group Commercial |
$40.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$61.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$57.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$43.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$63.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.77
|
| Rate for Payer: Multiplan Commercial |
$51.18
|
| Rate for Payer: Networks By Design Commercial |
$34.12
|
| Rate for Payer: Prime Health Services Commercial |
$58.00
|
| Rate for Payer: Riverside University Health System MISP |
$27.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$40.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$40.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.61
|
| Rate for Payer: United Healthcare All Other HMO |
$24.93
|
| Rate for Payer: United Healthcare HMO Rider |
$24.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58.00
|
| Rate for Payer: Vantage Medical Group Senior |
$58.00
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
IP
|
$117.19
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$105.47 |
| Rate for Payer: Adventist Health Commercial |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$93.99
|
| Rate for Payer: Blue Shield of California EPN |
$59.06
|
| Rate for Payer: Cash Price |
$52.74
|
| Rate for Payer: Central Health Plan Commercial |
$93.75
|
| Rate for Payer: Cigna of CA HMO |
$82.03
|
| Rate for Payer: Cigna of CA PPO |
$82.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.88
|
| Rate for Payer: EPIC Health Plan Senior |
$46.88
|
| Rate for Payer: Galaxy Health WC |
$99.61
|
| Rate for Payer: Global Benefits Group Commercial |
$70.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.44
|
| Rate for Payer: Multiplan Commercial |
$87.89
|
| Rate for Payer: Networks By Design Commercial |
$58.59
|
| Rate for Payer: Prime Health Services Commercial |
$99.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.98
|
| Rate for Payer: United Healthcare All Other HMO |
$42.81
|
| Rate for Payer: United Healthcare HMO Rider |
$41.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.38
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
OP
|
$117.19
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$239.72 |
| Rate for Payer: Adventist Health Commercial |
$23.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$239.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$87.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$81.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.56
|
| Rate for Payer: Blue Shield of California Commercial |
$60.54
|
| Rate for Payer: Blue Shield of California EPN |
$55.04
|
| Rate for Payer: Cash Price |
$52.74
|
| Rate for Payer: Cash Price |
$52.74
|
| Rate for Payer: Central Health Plan Commercial |
$93.75
|
| Rate for Payer: Cigna of CA HMO |
$82.03
|
| Rate for Payer: Cigna of CA PPO |
$82.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.88
|
| Rate for Payer: EPIC Health Plan Senior |
$46.88
|
| Rate for Payer: Galaxy Health WC |
$99.61
|
| Rate for Payer: Global Benefits Group Commercial |
$70.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$40.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$83.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$82.03
|
| Rate for Payer: Multiplan Commercial |
$87.89
|
| Rate for Payer: Networks By Design Commercial |
$58.59
|
| Rate for Payer: Prime Health Services Commercial |
$99.61
|
| Rate for Payer: Riverside University Health System MISP |
$46.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.98
|
| Rate for Payer: United Healthcare All Other HMO |
$42.81
|
| Rate for Payer: United Healthcare HMO Rider |
$41.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.61
|
| Rate for Payer: Vantage Medical Group Senior |
$99.61
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
IP
|
$114.94
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.99 |
| Max. Negotiated Rate |
$103.45 |
| Rate for Payer: Adventist Health Commercial |
$22.99
|
| Rate for Payer: Blue Shield of California Commercial |
$92.18
|
| Rate for Payer: Blue Shield of California EPN |
$57.93
|
| Rate for Payer: Cash Price |
$51.72
|
| Rate for Payer: Central Health Plan Commercial |
$91.95
|
| Rate for Payer: Cigna of CA HMO |
$80.46
|
| Rate for Payer: Cigna of CA PPO |
$80.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$80.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.98
|
| Rate for Payer: EPIC Health Plan Senior |
$45.98
|
| Rate for Payer: Galaxy Health WC |
$97.70
|
| Rate for Payer: Global Benefits Group Commercial |
$68.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$103.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.99
|
| Rate for Payer: Multiplan Commercial |
$86.20
|
| Rate for Payer: Networks By Design Commercial |
$57.47
|
| Rate for Payer: Prime Health Services Commercial |
$97.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.14
|
| Rate for Payer: United Healthcare All Other HMO |
$41.99
|
| Rate for Payer: United Healthcare HMO Rider |
$41.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.64
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
OP
|
$114.94
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.99 |
| Max. Negotiated Rate |
$239.72 |
| Rate for Payer: Adventist Health Commercial |
$22.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$239.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$81.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.56
|
| Rate for Payer: Blue Shield of California Commercial |
$60.54
|
| Rate for Payer: Blue Shield of California EPN |
$55.04
|
| Rate for Payer: Cash Price |
$51.72
|
| Rate for Payer: Cash Price |
$51.72
|
| Rate for Payer: Central Health Plan Commercial |
$91.95
|
| Rate for Payer: Cigna of CA HMO |
$80.46
|
| Rate for Payer: Cigna of CA PPO |
$80.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$80.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.98
|
| Rate for Payer: EPIC Health Plan Senior |
$45.98
|
| Rate for Payer: Galaxy Health WC |
$97.70
|
| Rate for Payer: Global Benefits Group Commercial |
$68.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$103.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$40.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$83.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.46
|
| Rate for Payer: Multiplan Commercial |
$86.20
|
| Rate for Payer: Networks By Design Commercial |
$57.47
|
| Rate for Payer: Prime Health Services Commercial |
$97.70
|
| Rate for Payer: Riverside University Health System MISP |
$45.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.14
|
| Rate for Payer: United Healthcare All Other HMO |
$41.99
|
| Rate for Payer: United Healthcare HMO Rider |
$41.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.70
|
| Rate for Payer: Vantage Medical Group Senior |
$97.70
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
OP
|
$152.14
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.43 |
| Max. Negotiated Rate |
$782.61 |
| Rate for Payer: Adventist Health Commercial |
$30.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$782.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$129.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$83.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$114.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$96.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$120.01
|
| Rate for Payer: Blue Shield of California Commercial |
$150.35
|
| Rate for Payer: Blue Shield of California EPN |
$136.68
|
| Rate for Payer: Cash Price |
$68.46
|
| Rate for Payer: Cash Price |
$68.46
|
| Rate for Payer: Central Health Plan Commercial |
$121.71
|
| Rate for Payer: Cigna of CA HMO |
$106.50
|
| Rate for Payer: Cigna of CA PPO |
$106.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$129.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$106.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.86
|
| Rate for Payer: EPIC Health Plan Senior |
$60.86
|
| Rate for Payer: Galaxy Health WC |
$129.32
|
| Rate for Payer: Global Benefits Group Commercial |
$91.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$136.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$225.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$96.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$249.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$89.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$106.50
|
| Rate for Payer: Multiplan Commercial |
$114.11
|
| Rate for Payer: Networks By Design Commercial |
$76.07
|
| Rate for Payer: Prime Health Services Commercial |
$129.32
|
| Rate for Payer: Riverside University Health System MISP |
$60.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$91.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$91.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.10
|
| Rate for Payer: United Healthcare All Other HMO |
$55.58
|
| Rate for Payer: United Healthcare HMO Rider |
$54.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$129.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.32
|
| Rate for Payer: Vantage Medical Group Senior |
$129.32
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
IP
|
$152.14
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.43 |
| Max. Negotiated Rate |
$136.93 |
| Rate for Payer: Adventist Health Commercial |
$30.43
|
| Rate for Payer: Blue Shield of California Commercial |
$122.02
|
| Rate for Payer: Blue Shield of California EPN |
$76.68
|
| Rate for Payer: Cash Price |
$68.46
|
| Rate for Payer: Central Health Plan Commercial |
$121.71
|
| Rate for Payer: Cigna of CA HMO |
$106.50
|
| Rate for Payer: Cigna of CA PPO |
$106.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$106.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.86
|
| Rate for Payer: EPIC Health Plan Senior |
$60.86
|
| Rate for Payer: Galaxy Health WC |
$129.32
|
| Rate for Payer: Global Benefits Group Commercial |
$91.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$136.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$96.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$89.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.43
|
| Rate for Payer: Multiplan Commercial |
$114.11
|
| Rate for Payer: Networks By Design Commercial |
$76.07
|
| Rate for Payer: Prime Health Services Commercial |
$129.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.10
|
| Rate for Payer: United Healthcare All Other HMO |
$55.58
|
| Rate for Payer: United Healthcare HMO Rider |
$54.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.83
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 6498013310
|
| 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
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6498013310
|
| 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
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 6498013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Riverside University Health System MISP |
$1.22
|
| 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 6498013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994080265
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| 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 |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994080265
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| 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
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 0025275231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.15 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.33
|
| Rate for Payer: Blue Shield of California Commercial |
$3.63
|
| Rate for Payer: Blue Shield of California EPN |
$2.28
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Central Health Plan Commercial |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.29
|
| Rate for Payer: EPIC Health Plan Senior |
$2.29
|
| Rate for Payer: Galaxy Health WC |
$4.86
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Networks By Design Commercial |
$3.72
|
| Rate for Payer: Prime Health Services Commercial |
$4.86
|
| Rate for Payer: Riverside University Health System MISP |
$2.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.86
|
| Rate for Payer: United Healthcare HMO Rider |
$2.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
NDC 0025275231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.15 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California Commercial |
$4.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.88
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Central Health Plan Commercial |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.29
|
| Rate for Payer: EPIC Health Plan Senior |
$2.29
|
| Rate for Payer: Galaxy Health WC |
$4.86
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Networks By Design Commercial |
$3.72
|
| Rate for Payer: Prime Health Services Commercial |
$4.86
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 0093312701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Central Health Plan Commercial |
$1.91
|
| 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 Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.96
|
| 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 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 0093312701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Central Health Plan Commercial |
$1.91
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 0093312901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.17
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Central Health Plan Commercial |
$2.16
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$1.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.29
|
| Rate for Payer: Global Benefits Group Commercial |
$1.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.75
|
| Rate for Payer: Prime Health Services Commercial |
$2.29
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
NDC 0025276231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$5.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.41
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Central Health Plan Commercial |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$4.73
|
| Rate for Payer: Cigna of CA PPO |
$4.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: EPIC Health Plan Senior |
$2.70
|
| Rate for Payer: Galaxy Health WC |
$5.75
|
| Rate for Payer: Global Benefits Group Commercial |
$4.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Networks By Design Commercial |
$4.39
|
| Rate for Payer: Prime Health Services Commercial |
$5.75
|
|
