|
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 |
$0.37 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.19
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| 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 |
$1.12 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.25
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.06
|
|
|
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 |
$2.13 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Adventist Health Commercial |
$2.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.83
|
| Rate for Payer: Blue Shield of California Commercial |
$7.31
|
| Rate for Payer: Blue Shield of California EPN |
$6.91
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.00
|
| Rate for Payer: Dignity Health Senior |
$10.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.45
|
| Rate for Payer: Heritage Provider Network Senior |
$5.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.71
|
| Rate for Payer: TriValley Medical Group Senior |
$4.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.93
|
| 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 60687-386-11
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Adventist Health Commercial |
$2.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.09
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.97
|
| Rate for Payer: Heritage Provider Network Senior |
$7.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.93
|
|
|
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 |
$2.13 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Adventist Health Commercial |
$2.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.83
|
| Rate for Payer: Blue Shield of California Commercial |
$7.31
|
| Rate for Payer: Blue Shield of California EPN |
$6.91
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.00
|
| Rate for Payer: Dignity Health Senior |
$10.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.45
|
| Rate for Payer: Heritage Provider Network Senior |
$5.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.71
|
| Rate for Payer: TriValley Medical Group Senior |
$4.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.93
|
| 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
|
$11.57
|
|
|
Service Code
|
NDC 0904-6746-04
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Adventist Health Commercial |
$2.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.68
|
| Rate for Payer: Blue Shield of California Commercial |
$7.18
|
| Rate for Payer: Blue Shield of California EPN |
$6.79
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.83
|
| Rate for Payer: Dignity Health Senior |
$9.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.36
|
| Rate for Payer: Heritage Provider Network Senior |
$5.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$8.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.83
|
| Rate for Payer: Vantage Medical Group Senior |
$9.83
|
|
|
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 |
$2.13 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Adventist Health Commercial |
$2.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.09
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.97
|
| Rate for Payer: Heritage Provider Network Senior |
$7.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.93
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
IP
|
$11.57
|
|
|
Service Code
|
NDC 0904-6746-04
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Adventist Health Commercial |
$2.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.95
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.83
|
| Rate for Payer: Heritage Provider Network Senior |
$7.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$8.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.87
|
|
|
DRONEDARONE 400 MG TABLET [98329]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 0024-4142-60
|
| Hospital Charge Code |
1712418
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Adventist Health Commercial |
$3.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.44
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.29
|
| Rate for Payer: Heritage Provider Network Senior |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$11.40
|
|
|
DRONEDARONE 400 MG TABLET [98329]
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 0024-4142-60
|
| Hospital Charge Code |
1712418
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Adventist Health Commercial |
$3.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.44
|
| Rate for Payer: Blue Shield of California EPN |
$8.92
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.92
|
| Rate for Payer: Dignity Health Senior |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.41
|
| Rate for Payer: Heritage Provider Network Senior |
$9.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$11.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.08
|
| Rate for Payer: TriValley Medical Group Senior |
$6.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.92
|
| Rate for Payer: Vantage Medical Group Senior |
$12.92
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]
|
Facility
|
IP
|
$5.37
|
|
|
Service Code
|
CPT J1790
|
| Hospital Charge Code |
NDG2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.69
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.64
|
| Rate for Payer: Heritage Provider Network Senior |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]
|
Facility
|
OP
|
$5.37
|
|
|
Service Code
|
CPT J1790
|
| Hospital Charge Code |
NDG2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$21.67 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.53
|
| Rate for Payer: Blue Shield of California Commercial |
$8.78
|
| Rate for Payer: Blue Shield of California EPN |
$8.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.56
|
| Rate for Payer: Dignity Health Senior |
$4.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.49
|
| Rate for Payer: Heritage Provider Network Senior |
$2.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Senior |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.56
|
| Rate for Payer: Vantage Medical Group Senior |
$4.56
|
|
|
DROXIDOPA 100 MG CAPSULE [206920]
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 0054-0532-22
|
| Hospital Charge Code |
ERX206920
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.14
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
|
|
DROXIDOPA 100 MG CAPSULE [206920]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 0054-0532-22
|
| Hospital Charge Code |
ERX206920
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.41
|
| Rate for Payer: Dignity Health Senior |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Vantage Medical Group Senior |
$1.41
|
|
|
DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$10,983.65
|
|
|
Service Code
|
APR-DRG 7704
|
| Min. Negotiated Rate |
$10,983.65 |
| Max. Negotiated Rate |
$10,983.65 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,983.65
|
|
|
DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$5,394.33
|
|
|
Service Code
|
APR-DRG 7703
|
| Min. Negotiated Rate |
$5,394.33 |
| Max. Negotiated Rate |
$5,394.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,394.33
|
|
|
DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$3,405.53
|
|
|
Service Code
|
APR-DRG 7702
|
| Min. Negotiated Rate |
$3,405.53 |
| Max. Negotiated Rate |
$3,405.53 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,405.53
|
|
|
DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$2,225.58
|
|
|
Service Code
|
APR-DRG 7701
|
| Min. Negotiated Rate |
$2,225.58 |
| Max. Negotiated Rate |
$2,225.58 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,225.58
|
|
|
Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep-disordered breathing, flexible, diagnostic
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 42975
|
| Min. Negotiated Rate |
$151.01 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,120.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,332.68
|
| Rate for Payer: Dignity Health Senior |
$2,120.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,120.62
|
| Rate for Payer: Humana Medicare |
$2,120.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$151.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,120.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,029.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,502.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,671.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,671.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,332.68
|
| Rate for Payer: TriValley Medical Group Senior |
$2,120.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,120.62
|
|
|
DTAP-POLIO-HIB CONJ-TET(PF) 15 LF-48MCG-5 LF-62 DU-10MCG/ 0.5ML IM KIT [227486]
|
Facility
|
OP
|
$129.06
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
ERX227486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Adventist Health Commercial |
$25.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$109.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$70.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$96.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$103.85
|
| Rate for Payer: Blue Shield of California Commercial |
$107.66
|
| Rate for Payer: Blue Shield of California EPN |
$107.66
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$109.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$109.70
|
| Rate for Payer: Dignity Health Senior |
$109.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.75
|
| Rate for Payer: Heritage Provider Network Senior |
$59.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$173.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.62
|
| Rate for Payer: TriValley Medical Group Senior |
$51.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$109.70
|
| Rate for Payer: Vantage Medical Group Senior |
$109.70
|
|
|
DTAP-POLIO-HIB CONJ-TET(PF) 15 LF-48MCG-5 LF-62 DU-10MCG/ 0.5ML IM KIT [227486]
|
Facility
|
IP
|
$129.06
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
ERX227486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$96.80 |
| Rate for Payer: Adventist Health Commercial |
$25.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.66
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.37
|
| Rate for Payer: Heritage Provider Network Senior |
$87.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.12
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 68084-675-21
|
| Hospital Charge Code |
1711839
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 68001-413-06
|
| Hospital Charge Code |
1711839
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 68084-675-11
|
| Hospital Charge Code |
1711839
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 68001-413-06
|
| Hospital Charge Code |
1711839
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
