|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [110910]
|
Facility
IP
|
$1.01
|
|
|
Service Code
|
NDC 23155-135-25
|
| Hospital Charge Code |
1712560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Central Health Plan Commercial |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.86
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.86
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9901]
|
Facility
IP
|
$0.65
|
|
|
Service Code
|
NDC 50268-280-11
|
| Hospital Charge Code |
ERX9901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9901]
|
Facility
OP
|
$0.65
|
|
|
Service Code
|
NDC 50268-280-11
|
| Hospital Charge Code |
ERX9901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.49
|
| Rate for Payer: IEHP medi-cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.39
|
| Rate for Payer: Riverside University Health MISP |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE [186780]
|
Facility
IP
|
$6.53
|
|
|
Service Code
|
NDC 55494-100-10
|
| Hospital Charge Code |
ERX186780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| Rate for Payer: Cigna of CA HMO |
$4.57
|
| Rate for Payer: Cigna of CA PPO |
$4.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.55
|
| Rate for Payer: Global Benefits Group Commercial |
$3.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$4.90
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.55
|
|
|
DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE [186780]
|
Facility
OP
|
$6.53
|
|
|
Service Code
|
NDC 55494-100-10
|
| Hospital Charge Code |
ERX186780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.86
|
| Rate for Payer: BCBS Transplant Transplant |
$3.92
|
| Rate for Payer: Blue Shield of California Commercial |
$4.11
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| Rate for Payer: Cigna of CA HMO |
$4.57
|
| Rate for Payer: Cigna of CA PPO |
$4.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.55
|
| Rate for Payer: Global Benefits Group Commercial |
$3.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.90
|
| Rate for Payer: IEHP medi-cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$4.90
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.55
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.92
|
| Rate for Payer: Riverside University Health MISP |
$2.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.26
|
| Rate for Payer: United Healthcare All Other HMO |
$3.26
|
| Rate for Payer: United Healthcare HMO Rider |
$3.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.55
|
| Rate for Payer: Vantage Medical Group Senior |
$5.55
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 24385-441-64
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.13
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| 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: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| 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
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 24385-441-64
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 4116700607
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| 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: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| 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
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 4116700607
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| 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: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| 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
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| 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: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.17
|
| 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
|
|
|
DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT [92074]
|
Facility
OP
|
$122.91
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
1720996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.58 |
| Max. Negotiated Rate |
$725.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$725.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$104.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$67.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$67.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$96.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$105.30
|
| Rate for Payer: BCBS Transplant Transplant |
$73.75
|
| Rate for Payer: Blue Shield of California Commercial |
$130.96
|
| Rate for Payer: Blue Shield of California EPN |
$119.05
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Central Health Plan Commercial |
$98.33
|
| Rate for Payer: Cigna of CA HMO |
$86.04
|
| Rate for Payer: Cigna of CA PPO |
$86.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$104.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$49.16
|
| Rate for Payer: Galaxy Health WC |
$104.47
|
| Rate for Payer: Global Benefits Group Commercial |
$73.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$110.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$92.18
|
| Rate for Payer: IEHP medi-cal |
$43.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$81.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.58
|
| Rate for Payer: Multiplan Commercial |
$92.18
|
| Rate for Payer: Networks By Design Commercial |
$61.46
|
| Rate for Payer: Prime Health Services Commercial |
$104.47
|
| Rate for Payer: Riverside University Health MISP |
$49.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$73.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$73.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$61.46
|
| Rate for Payer: United Healthcare All Other HMO |
$61.46
|
| Rate for Payer: United Healthcare HMO Rider |
$61.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$61.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$104.47
|
| Rate for Payer: Vantage Medical Group Senior |
$104.47
|
|
|
DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT [92074]
|
Facility
IP
|
$122.91
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
1720996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.58 |
| Max. Negotiated Rate |
$110.62 |
| Rate for Payer: Blue Shield of California Commercial |
$92.18
|
| Rate for Payer: Blue Shield of California EPN |
$65.63
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Central Health Plan Commercial |
$98.33
|
| Rate for Payer: Cigna of CA HMO |
$86.04
|
| Rate for Payer: Cigna of CA PPO |
$86.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$49.16
|
| Rate for Payer: Galaxy Health WC |
$104.47
|
| Rate for Payer: Global Benefits Group Commercial |
$73.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$110.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$81.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.58
|
| Rate for Payer: Multiplan Commercial |
$92.18
|
| Rate for Payer: Networks By Design Commercial |
$61.46
|
| Rate for Payer: Prime Health Services Commercial |
$104.47
|
|
|
Drainage of abscess, cyst, hematoma from dentoalveolar structures
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 41800
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$159.60 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$159.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$239.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$175.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$159.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$159.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.46
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$159.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$159.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$261.74
|
| Rate for Payer: IEHP medi-cal |
$263.34
|
| Rate for Payer: IEHP Medicare Advantage |
$159.60
|
| Rate for Payer: Innovage PACE Commercial |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$159.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$213.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$213.86
|
| Rate for Payer: Prime Health Services Medicare |
$169.18
|
| Rate for Payer: Riverside University Health MISP |
$175.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$239.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$175.56
|
| Rate for Payer: Vantage Medical Group Senior |
$159.60
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
IP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-01
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| Rate for Payer: Cigna of CA HMO |
$4.33
|
| Rate for Payer: Cigna of CA PPO |
$4.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: Networks By Design Commercial |
$3.09
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
IP
|
$2.02
|
|
|
Service Code
|
NDC 67877-753-60
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.81
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
OP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-01
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.65
|
| Rate for Payer: BCBS Transplant Transplant |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.02
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| Rate for Payer: Cigna of CA HMO |
$4.33
|
| Rate for Payer: Cigna of CA PPO |
$4.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.64
|
| Rate for Payer: IEHP medi-cal |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: Networks By Design Commercial |
$3.09
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
| Rate for Payer: Riverside University Health MISP |
$2.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.09
|
| Rate for Payer: United Healthcare All Other HMO |
$3.09
|
| Rate for Payer: United Healthcare HMO Rider |
$3.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.25
|
| Rate for Payer: Vantage Medical Group Senior |
$5.25
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
OP
|
$2.02
|
|
|
Service Code
|
NDC 67877-753-60
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: BCBS Transplant Transplant |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.81
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.52
|
| Rate for Payer: IEHP medi-cal |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
| Rate for Payer: Riverside University Health MISP |
$0.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.01
|
| Rate for Payer: United Healthcare All Other HMO |
$1.01
|
| Rate for Payer: United Healthcare HMO Rider |
$1.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
IP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-11
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| Rate for Payer: Cigna of CA HMO |
$4.33
|
| Rate for Payer: Cigna of CA PPO |
$4.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: Networks By Design Commercial |
$3.09
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
OP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-11
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.65
|
| Rate for Payer: BCBS Transplant Transplant |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.02
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| Rate for Payer: Cigna of CA HMO |
$4.33
|
| Rate for Payer: Cigna of CA PPO |
$4.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.64
|
| Rate for Payer: IEHP medi-cal |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: Networks By Design Commercial |
$3.09
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
| Rate for Payer: Riverside University Health MISP |
$2.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.09
|
| Rate for Payer: United Healthcare All Other HMO |
$3.09
|
| Rate for Payer: United Healthcare HMO Rider |
$3.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.25
|
| Rate for Payer: Vantage Medical Group Senior |
$5.25
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
OP
|
$11.77
|
|
|
Service Code
|
NDC 60687-386-11
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.95
|
| Rate for Payer: BCBS Transplant Transplant |
$7.06
|
| Rate for Payer: Blue Shield of California Commercial |
$7.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.76
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Central Health Plan Commercial |
$9.42
|
| Rate for Payer: Cigna of CA HMO |
$8.24
|
| Rate for Payer: Cigna of CA PPO |
$8.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.71
|
| Rate for Payer: Galaxy Health WC |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$7.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.83
|
| Rate for Payer: IEHP medi-cal |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: Networks By Design Commercial |
$5.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.00
|
| Rate for Payer: Riverside University Health MISP |
$4.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Other HMO |
$5.88
|
| Rate for Payer: United Healthcare HMO Rider |
$5.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.00
|
| Rate for Payer: Vantage Medical Group Senior |
$10.00
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
OP
|
$11.77
|
|
|
Service Code
|
NDC 60687-386-21
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.95
|
| Rate for Payer: BCBS Transplant Transplant |
$7.06
|
| Rate for Payer: Blue Shield of California Commercial |
$7.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.76
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Central Health Plan Commercial |
$9.42
|
| Rate for Payer: Cigna of CA HMO |
$8.24
|
| Rate for Payer: Cigna of CA PPO |
$8.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.71
|
| Rate for Payer: Galaxy Health WC |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$7.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.83
|
| Rate for Payer: IEHP medi-cal |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: Networks By Design Commercial |
$5.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.00
|
| Rate for Payer: Riverside University Health MISP |
$4.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Other HMO |
$5.88
|
| Rate for Payer: United Healthcare HMO Rider |
$5.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.00
|
| Rate for Payer: Vantage Medical Group Senior |
$10.00
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
IP
|
$11.77
|
|
|
Service Code
|
NDC 60687-386-21
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Blue Shield of California Commercial |
$8.83
|
| Rate for Payer: Blue Shield of California EPN |
$6.29
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Central Health Plan Commercial |
$9.42
|
| Rate for Payer: Cigna of CA HMO |
$8.24
|
| Rate for Payer: Cigna of CA PPO |
$8.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.71
|
| Rate for Payer: Galaxy Health WC |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$7.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: Networks By Design Commercial |
$5.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.00
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
IP
|
$11.77
|
|
|
Service Code
|
NDC 60687-386-11
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Blue Shield of California Commercial |
$8.83
|
| Rate for Payer: Blue Shield of California EPN |
$6.29
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Central Health Plan Commercial |
$9.42
|
| Rate for Payer: Cigna of CA HMO |
$8.24
|
| Rate for Payer: Cigna of CA PPO |
$8.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.71
|
| Rate for Payer: Galaxy Health WC |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$7.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: Networks By Design Commercial |
$5.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.00
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
OP
|
$11.57
|
|
|
Service Code
|
NDC 0904-6746-04
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$10.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.84
|
| Rate for Payer: BCBS Transplant Transplant |
$6.94
|
| Rate for Payer: Blue Shield of California Commercial |
$7.28
|
| Rate for Payer: Blue Shield of California EPN |
$5.66
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Central Health Plan Commercial |
$9.26
|
| Rate for Payer: Cigna of CA HMO |
$8.10
|
| Rate for Payer: Cigna of CA PPO |
$8.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.63
|
| Rate for Payer: Galaxy Health WC |
$9.83
|
| Rate for Payer: Global Benefits Group Commercial |
$6.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.41
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.68
|
| Rate for Payer: IEHP medi-cal |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$8.68
|
| Rate for Payer: Networks By Design Commercial |
$5.78
|
| Rate for Payer: Prime Health Services Commercial |
$9.83
|
| Rate for Payer: Riverside University Health MISP |
$4.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.78
|
| Rate for Payer: United Healthcare All Other HMO |
$5.78
|
| Rate for Payer: United Healthcare HMO Rider |
$5.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.83
|
| Rate for Payer: Vantage Medical Group Senior |
$9.83
|
|
