|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$3.79
|
|
|
Service Code
|
NDC 68462-851-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.84
|
| Rate for Payer: Blue Shield of California Commercial |
$2.35
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.22
|
| Rate for Payer: Dignity Health Senior |
$3.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Senior |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$2.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.52
|
| Rate for Payer: TriValley Medical Group Senior |
$1.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.22
|
| Rate for Payer: Vantage Medical Group Senior |
$3.22
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.21
|
| 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: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.74
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.97
|
| Rate for Payer: Dignity Health Senior |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.97
|
| Rate for Payer: Vantage Medical Group Senior |
$3.97
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-20
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.21
|
| 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: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.74
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.97
|
| Rate for Payer: Dignity Health Senior |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.97
|
| Rate for Payer: Vantage Medical Group Senior |
$3.97
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-20
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.21
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 0378-6090-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.39
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.36
|
| Rate for Payer: Heritage Provider Network Senior |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 51079-925-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.21
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$3.48
|
|
|
Service Code
|
NDC 0378-6090-01
|
| Hospital Charge Code |
1711272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.16
|
| Rate for Payer: Blue Shield of California EPN |
$2.04
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.96
|
| Rate for Payer: Dignity Health Senior |
$2.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Senior |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.96
|
| Rate for Payer: Vantage Medical Group Senior |
$2.96
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| 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: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| 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 |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| 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: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| 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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| 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: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$2.51 |
| Max. Negotiated Rate |
$10.38 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.51
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.37
|
| Rate for Payer: Heritage Provider Network Senior |
$9.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$10.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.62
|
|
|
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 |
$2.51 |
| Max. Negotiated Rate |
$21.99 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$10.23
|
| Rate for Payer: Blue Shield of California EPN |
$10.23
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.76
|
| Rate for Payer: Dignity Health Senior |
$11.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.41
|
| Rate for Payer: Heritage Provider Network Senior |
$6.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$10.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.54
|
| Rate for Payer: TriValley Medical Group Senior |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.62
|
| 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 |
$109.43 |
| Max. Negotiated Rate |
$453.45 |
| Rate for Payer: Adventist Health Commercial |
$120.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$415.36
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$278.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$326.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$409.31
|
| Rate for Payer: Heritage Provider Network Senior |
$409.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.15
|
| Rate for Payer: Multiplan Commercial |
$453.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$220.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$202.00
|
|
|
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 |
$109.43 |
| Max. Negotiated Rate |
$513.91 |
| Rate for Payer: Adventist Health Commercial |
$120.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$323.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$415.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$513.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$332.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.45
|
| Rate for Payer: Blue Shield of California Commercial |
$375.46
|
| Rate for Payer: Blue Shield of California EPN |
$354.90
|
| Rate for Payer: Cash Price |
$272.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$278.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$513.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$513.91
|
| Rate for Payer: Dignity Health Senior |
$513.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$386.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$279.93
|
| Rate for Payer: Heritage Provider Network Senior |
$279.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$291.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.15
|
| Rate for Payer: Multiplan Commercial |
$453.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$241.84
|
| Rate for Payer: TriValley Medical Group Senior |
$241.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$220.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$202.00
|
| 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
|
OP
|
$3,784.85
|
|
|
Service Code
|
NDC 66302-014-01
|
| Hospital Charge Code |
NDG209941
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$685.06 |
| Max. Negotiated Rate |
$3,217.12 |
| Rate for Payer: Adventist Health Commercial |
$756.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,023.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,600.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,217.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,081.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,838.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2,350.39
|
| Rate for Payer: Blue Shield of California EPN |
$2,221.71
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,741.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,217.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,217.12
|
| Rate for Payer: Dignity Health Senior |
$3,217.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,422.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,752.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1,752.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,824.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$685.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$946.21
|
| Rate for Payer: Multiplan Commercial |
$2,838.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,513.94
|
| Rate for Payer: TriValley Medical Group Senior |
$1,513.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,379.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,264.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,217.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3,217.12
|
|
|
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 |
$685.06 |
| Max. Negotiated Rate |
$2,838.64 |
| Rate for Payer: Adventist Health Commercial |
$756.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,600.19
|
| Rate for Payer: Cash Price |
$1,703.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,741.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,043.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,562.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2,562.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$685.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$946.21
|
| Rate for Payer: Multiplan Commercial |
$2,838.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,379.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,264.52
|
|
|
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: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
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 |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Senior |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
