|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 9994-0802-64
|
| Hospital Charge Code |
1715006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| 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: 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: 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 |
1715006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: BCBS Transplant Transplant |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| 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: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.34
|
| Rate for Payer: IEHP medi-cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-01
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-09
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.21
|
| Rate for Payer: IEHP medi-cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Riverside University Health MISP |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-01
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.21
|
| Rate for Payer: IEHP medi-cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Riverside University Health MISP |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) INTRAVENOUS SOLUTION [111405]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 0703-9258-09
|
| Hospital Charge Code |
NDG111405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.26
|
| Rate for Payer: IEHP medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| 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 |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.26
|
| Rate for Payer: IEHP medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| 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 |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-02
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| 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 |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 0173-0857-01
|
| Hospital Charge Code |
NDG228006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| 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 |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
IP
|
$13.84
|
|
|
Service Code
|
CPT J1240
|
| Hospital Charge Code |
NDG2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Blue Shield of California Commercial |
$10.38
|
| Rate for Payer: Blue Shield of California EPN |
$7.39
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Central Health Plan Commercial |
$11.07
|
| Rate for Payer: Cigna of CA HMO |
$9.69
|
| Rate for Payer: Cigna of CA PPO |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.54
|
| Rate for Payer: Galaxy Health WC |
$11.76
|
| Rate for Payer: Global Benefits Group Commercial |
$8.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$10.38
|
| Rate for Payer: Networks By Design Commercial |
$6.92
|
| Rate for Payer: Prime Health Services Commercial |
$11.76
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
OP
|
$13.84
|
|
|
Service Code
|
CPT J1240
|
| Hospital Charge Code |
NDG2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$55.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.61
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.48
|
| Rate for Payer: BCBS Transplant Transplant |
$8.30
|
| Rate for Payer: Blue Shield of California Commercial |
$13.24
|
| Rate for Payer: Blue Shield of California EPN |
$12.04
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Central Health Plan Commercial |
$11.07
|
| Rate for Payer: Cigna of CA HMO |
$9.69
|
| Rate for Payer: Cigna of CA PPO |
$9.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.54
|
| Rate for Payer: Galaxy Health WC |
$11.76
|
| Rate for Payer: Global Benefits Group Commercial |
$8.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10.38
|
| Rate for Payer: IEHP medi-cal |
$8.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$10.38
|
| Rate for Payer: Networks By Design Commercial |
$6.92
|
| Rate for Payer: Prime Health Services Commercial |
$11.76
|
| Rate for Payer: Riverside University Health MISP |
$5.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.92
|
| Rate for Payer: United Healthcare All Other HMO |
$6.92
|
| Rate for Payer: United Healthcare HMO Rider |
$6.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.76
|
| Rate for Payer: Vantage Medical Group Senior |
$11.76
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
IP
|
$604.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1749027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.92 |
| Max. Negotiated Rate |
$544.14 |
| Rate for Payer: Blue Shield of California Commercial |
$453.45
|
| Rate for Payer: Blue Shield of California EPN |
$322.86
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Central Health Plan Commercial |
$483.68
|
| Rate for Payer: Cigna of CA HMO |
$423.22
|
| Rate for Payer: Cigna of CA PPO |
$423.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$241.84
|
| Rate for Payer: Galaxy Health WC |
$513.91
|
| Rate for Payer: Global Benefits Group Commercial |
$362.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$544.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$403.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.92
|
| Rate for Payer: Multiplan Commercial |
$453.45
|
| Rate for Payer: Networks By Design Commercial |
$302.30
|
| Rate for Payer: Prime Health Services Commercial |
$513.91
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
OP
|
$604.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1749027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.92 |
| Max. Negotiated Rate |
$544.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$367.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$513.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$332.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$332.53
|
| Rate for Payer: BCBS Transplant Transplant |
$362.76
|
| Rate for Payer: Blue Shield of California Commercial |
$380.29
|
| Rate for Payer: Blue Shield of California EPN |
$295.65
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Central Health Plan Commercial |
$483.68
|
| Rate for Payer: Cigna of CA HMO |
$423.22
|
| Rate for Payer: Cigna of CA PPO |
$423.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$513.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$241.84
|
| Rate for Payer: Galaxy Health WC |
$513.91
|
| Rate for Payer: Global Benefits Group Commercial |
$362.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$544.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$453.45
|
| Rate for Payer: IEHP medi-cal |
$211.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$403.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.92
|
| Rate for Payer: Multiplan Commercial |
$453.45
|
| Rate for Payer: Networks By Design Commercial |
$302.30
|
| Rate for Payer: Prime Health Services Commercial |
$513.91
|
| Rate for Payer: Riverside University Health MISP |
$241.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$362.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$362.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$302.30
|
| Rate for Payer: United Healthcare All Other HMO |
$302.30
|
| Rate for Payer: United Healthcare HMO Rider |
$302.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$302.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$513.91
|
| Rate for Payer: Vantage Medical Group Senior |
$513.91
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
IP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$756.97 |
| Max. Negotiated Rate |
$3,406.36 |
| Rate for Payer: Blue Shield of California Commercial |
$2,838.64
|
| Rate for Payer: Blue Shield of California EPN |
$2,021.11
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Central Health Plan Commercial |
$3,027.88
|
| Rate for Payer: Cigna of CA HMO |
$2,649.40
|
| Rate for Payer: Cigna of CA PPO |
$2,649.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,513.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,513.94
|
| Rate for Payer: Galaxy Health WC |
$3,217.12
|
| Rate for Payer: Global Benefits Group Commercial |
$2,270.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,406.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,524.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$756.97
|
| Rate for Payer: Multiplan Commercial |
$2,838.64
|
| Rate for Payer: Networks By Design Commercial |
$1,892.42
|
| Rate for Payer: Prime Health Services Commercial |
$3,217.12
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
OP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$756.97 |
| Max. Negotiated Rate |
$3,406.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,298.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,217.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,081.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,081.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,832.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,236.09
|
| Rate for Payer: BCBS Transplant Transplant |
$2,270.91
|
| Rate for Payer: Blue Shield of California Commercial |
$2,380.67
|
| Rate for Payer: Blue Shield of California EPN |
$1,850.79
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Central Health Plan Commercial |
$3,027.88
|
| Rate for Payer: Cigna of CA HMO |
$2,649.40
|
| Rate for Payer: Cigna of CA PPO |
$2,649.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,217.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,513.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,513.94
|
| Rate for Payer: Galaxy Health WC |
$3,217.12
|
| Rate for Payer: Global Benefits Group Commercial |
$2,270.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,406.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,838.64
|
| Rate for Payer: IEHP medi-cal |
$1,324.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,524.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$756.97
|
| Rate for Payer: Multiplan Commercial |
$2,838.64
|
| Rate for Payer: Networks By Design Commercial |
$1,892.42
|
| Rate for Payer: Prime Health Services Commercial |
$3,217.12
|
| Rate for Payer: Riverside University Health MISP |
$1,513.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,270.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,270.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,892.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1,892.42
|
| Rate for Payer: United Healthcare HMO Rider |
$1,892.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,892.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,217.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3,217.12
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
OP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: BCBS Transplant Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.68
|
| Rate for Payer: IEHP medi-cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: Riverside University Health MISP |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$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: 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: 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 ELIXIR [2511]
|
Facility
OP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: BCBS Transplant Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.68
|
| Rate for Payer: IEHP medi-cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: Riverside University Health MISP |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 9999-2511-00
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare 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: BCBS Transplant Transplant |
$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: 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: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.01
|
| Rate for Payer: IEHP medi-cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
NDC 0121-0489-05
|
| Hospital Charge Code |
1716039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
OP
|
$0.38
|
|
|
Service Code
|
NDC 68094-022-62
|
| Hospital Charge Code |
NDG12556C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: BCBS Transplant Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.29
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: Riverside University Health MISP |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 58657-528-16
|
| Hospital Charge Code |
NDG12556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: EPIC Health Plan Commercial |
$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: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| 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
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
IP
|
$0.38
|
|
|
Service Code
|
NDC 68094-022-62
|
| Hospital Charge Code |
NDG12556C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
