|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Central Health Plan Commercial |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$3.27
|
| Rate for Payer: Cigna of CA PPO |
$3.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.87
|
| Rate for Payer: EPIC Health Plan Senior |
$1.87
|
| Rate for Payer: Galaxy Health WC |
$3.97
|
| Rate for Payer: Global Benefits Group Commercial |
$2.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.20
|
| Rate for Payer: InnovAge PACE Commercial |
$2.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.27
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$3.04
|
| Rate for Payer: Prime Health Services Commercial |
$3.97
|
| Rate for Payer: Riverside University Health System MISP |
$1.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.33
|
| Rate for Payer: United Healthcare All Other HMO |
$2.33
|
| Rate for Payer: United Healthcare HMO Rider |
$2.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.97
|
| Rate for Payer: Vantage Medical Group Senior |
$3.97
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: InnovAge PACE Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DILTIAZEM TOPICAL GEL 2 % (COMPOUNDED) [4081048]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 9994-0810-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
DILTIAZEM TOPICAL GEL 2 % (COMPOUNDED) [4081048]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 9994-0810-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| 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 |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: InnovAge PACE Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: InnovAge PACE Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: InnovAge PACE Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0781-6021-94
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: InnovAge PACE Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0781-6021-94
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 66302-150-50
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 66302-150-50
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| 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 |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: InnovAge PACE Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
IP
|
$15.77
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$14.19 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$12.19
|
| Rate for Payer: Blue Shield of California EPN |
$7.95
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Central Health Plan Commercial |
$12.62
|
| Rate for Payer: Cigna of CA HMO |
$11.04
|
| Rate for Payer: Cigna of CA PPO |
$11.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.31
|
| Rate for Payer: EPIC Health Plan Senior |
$6.31
|
| Rate for Payer: Galaxy Health WC |
$13.40
|
| Rate for Payer: Global Benefits Group Commercial |
$9.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$11.83
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$13.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Other HMO |
$5.76
|
| Rate for Payer: United Healthcare HMO Rider |
$5.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.16
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
OP
|
$15.77
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$28.90 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.87
|
| Rate for Payer: Blue Shield of California Commercial |
$15.22
|
| Rate for Payer: Blue Shield of California EPN |
$13.84
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Central Health Plan Commercial |
$12.62
|
| Rate for Payer: Cigna of CA HMO |
$11.04
|
| Rate for Payer: Cigna of CA PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.31
|
| Rate for Payer: EPIC Health Plan Senior |
$6.31
|
| Rate for Payer: Galaxy Health WC |
$13.40
|
| Rate for Payer: Global Benefits Group Commercial |
$9.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8.35
|
| Rate for Payer: InnovAge PACE Commercial |
$7.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.04
|
| Rate for Payer: Multiplan Commercial |
$11.83
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$13.40
|
| Rate for Payer: Riverside University Health System MISP |
$6.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Other HMO |
$5.76
|
| Rate for Payer: United Healthcare HMO Rider |
$5.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.40
|
| Rate for Payer: Vantage Medical Group Senior |
$13.40
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
IP
|
$660.22
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.04 |
| Max. Negotiated Rate |
$594.20 |
| Rate for Payer: Adventist Health Commercial |
$132.04
|
| Rate for Payer: Blue Shield of California Commercial |
$510.35
|
| Rate for Payer: Blue Shield of California EPN |
$332.75
|
| Rate for Payer: Cash Price |
$363.12
|
| Rate for Payer: Central Health Plan Commercial |
$528.18
|
| Rate for Payer: Cigna of CA HMO |
$462.15
|
| Rate for Payer: Cigna of CA PPO |
$462.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.09
|
| Rate for Payer: EPIC Health Plan Senior |
$264.09
|
| Rate for Payer: Galaxy Health WC |
$561.19
|
| Rate for Payer: Global Benefits Group Commercial |
$396.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$495.17
|
| Rate for Payer: Networks By Design Commercial |
$330.11
|
| Rate for Payer: Prime Health Services Commercial |
$561.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$247.78
|
| Rate for Payer: United Healthcare All Other HMO |
$241.18
|
| Rate for Payer: United Healthcare HMO Rider |
$235.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$216.22
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
OP
|
$660.22
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.04 |
| Max. Negotiated Rate |
$594.20 |
| Rate for Payer: Adventist Health Commercial |
$132.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$400.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$319.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$387.75
|
| Rate for Payer: Blue Shield of California Commercial |
$403.39
|
| Rate for Payer: Blue Shield of California EPN |
$263.43
|
| Rate for Payer: Cash Price |
$363.12
|
| Rate for Payer: Central Health Plan Commercial |
$528.18
|
| Rate for Payer: Cigna of CA HMO |
$462.15
|
| Rate for Payer: Cigna of CA PPO |
$462.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.09
|
| Rate for Payer: EPIC Health Plan Senior |
$264.09
|
| Rate for Payer: Galaxy Health WC |
$561.19
|
| Rate for Payer: Global Benefits Group Commercial |
$396.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.20
|
| Rate for Payer: InnovAge PACE Commercial |
$330.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.15
|
| Rate for Payer: Multiplan Commercial |
$495.17
|
| Rate for Payer: Networks By Design Commercial |
$330.11
|
| Rate for Payer: Prime Health Services Commercial |
$561.19
|
| Rate for Payer: Riverside University Health System MISP |
$264.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$247.78
|
| Rate for Payer: United Healthcare All Other HMO |
$241.18
|
| Rate for Payer: United Healthcare HMO Rider |
$235.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$216.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.19
|
| Rate for Payer: Vantage Medical Group Senior |
$561.19
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: InnovAge PACE Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
| Rate for Payer: Riverside University Health System MISP |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO |
$0.50
|
| Rate for Payer: United Healthcare HMO Rider |
$0.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: InnovAge PACE Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Riverside University Health System MISP |
$0.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: InnovAge PACE Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
| Rate for Payer: Riverside University Health System MISP |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO |
$0.50
|
| Rate for Payer: United Healthcare HMO Rider |
$0.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 69339-151-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: InnovAge PACE Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 58657-528-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
