|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
CPT J7060
|
| Hospital Charge Code |
1771009
|
|
Hospital Revenue Code
|
258
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$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 |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0719-06
|
| Hospital Charge Code |
NDG2367
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$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 Commercial |
$0.00
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7387-50
|
| Hospital Charge Code |
NDG2367
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7387-50
|
| Hospital Charge Code |
NDG2367
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$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 Commercial |
$0.00
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0719-06
|
| Hospital Charge Code |
NDG2367
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL [201988]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 2420802401
|
| Hospital Charge Code |
NDG40827466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL [201988]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 2420802401
|
| Hospital Charge Code |
NDG40827466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
DIABETES
|
Facility
IP
|
$14,220.05
|
|
|
Service Code
|
APR-DRG 4204
|
| Min. Negotiated Rate |
$14,220.05 |
| Max. Negotiated Rate |
$14,220.05 |
| Rate for Payer: IEHP Medi-Cal |
$14,220.05
|
|
|
DIABETES
|
Facility
IP
|
$7,271.69
|
|
|
Service Code
|
APR-DRG 4203
|
| Min. Negotiated Rate |
$7,271.69 |
| Max. Negotiated Rate |
$7,271.69 |
| Rate for Payer: IEHP Medi-Cal |
$7,271.69
|
|
|
DIABETES
|
Facility
IP
|
$4,918.76
|
|
|
Service Code
|
APR-DRG 4202
|
| Min. Negotiated Rate |
$4,918.76 |
| Max. Negotiated Rate |
$4,918.76 |
| Rate for Payer: IEHP Medi-Cal |
$4,918.76
|
|
|
DIABETES
|
Facility
IP
|
$3,827.37
|
|
|
Service Code
|
APR-DRG 4201
|
| Min. Negotiated Rate |
$3,827.37 |
| Max. Negotiated Rate |
$3,827.37 |
| Rate for Payer: IEHP Medi-Cal |
$3,827.37
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
CPT Q9963
|
| Hospital Charge Code |
NDG9828
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: IEHP Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Senior |
$75.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
CPT Q9963
|
| Hospital Charge Code |
NDG9828
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 51079-286-01
|
| Hospital Charge Code |
1730082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 51079-286-20
|
| Hospital Charge Code |
1730082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 51079-286-01
|
| Hospital Charge Code |
1730082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 0378-0477-01
|
| Hospital Charge Code |
1730082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 51079-286-20
|
| Hospital Charge Code |
1730082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 0378-0477-01
|
| Hospital Charge Code |
1730082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
DIAZEPAM 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT [87869]
|
Facility
OP
|
$420.90
|
|
|
Service Code
|
NDC 0187-0659-20
|
| Hospital Charge Code |
ERX87869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.18 |
| Max. Negotiated Rate |
$357.76 |
| Rate for Payer: Adventist Health Commercial |
$84.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$224.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$289.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$357.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$315.68
|
| Rate for Payer: Blue Shield of California Commercial |
$261.38
|
| Rate for Payer: Blue Shield of California EPN |
$247.07
|
| Rate for Payer: Cash Price |
$189.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$357.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$357.76
|
| Rate for Payer: Dignity Health Senior |
$357.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$260.54
|
| Rate for Payer: Heritage Provider Network Senior |
$260.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$202.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.22
|
| Rate for Payer: Multiplan Commercial |
$315.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$357.76
|
| Rate for Payer: Vantage Medical Group Senior |
$357.76
|
|
|
DIAZEPAM 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT [87869]
|
Facility
IP
|
$420.90
|
|
|
Service Code
|
NDC 0187-0659-20
|
| Hospital Charge Code |
ERX87869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.18 |
| Max. Negotiated Rate |
$315.68 |
| Rate for Payer: Adventist Health Commercial |
$84.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$289.16
|
| Rate for Payer: Cash Price |
$189.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$227.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$284.95
|
| Rate for Payer: Heritage Provider Network Senior |
$284.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.22
|
| Rate for Payer: Multiplan Commercial |
$315.68
|
|
|
DIAZEPAM 2.5 MG RECTAL KIT [87865]
|
Facility
OP
|
$354.82
|
|
|
Service Code
|
NDC 66490-650-20
|
| Hospital Charge Code |
1748085
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.22 |
| Max. Negotiated Rate |
$301.60 |
| Rate for Payer: Adventist Health Commercial |
$70.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$189.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$243.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$301.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$195.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$266.12
|
| Rate for Payer: Blue Shield of California Commercial |
$220.34
|
| Rate for Payer: Blue Shield of California EPN |
$208.28
|
| Rate for Payer: Cash Price |
$159.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$230.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.60
|
| Rate for Payer: Dignity Health Senior |
$301.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$227.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$219.63
|
| Rate for Payer: Heritage Provider Network Senior |
$219.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$171.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.70
|
| Rate for Payer: Multiplan Commercial |
$266.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.60
|
| Rate for Payer: Vantage Medical Group Senior |
$301.60
|
|
|
DIAZEPAM 2.5 MG RECTAL KIT [87865]
|
Facility
IP
|
$354.82
|
|
|
Service Code
|
NDC 66490-650-20
|
| Hospital Charge Code |
1748085
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.22 |
| Max. Negotiated Rate |
$266.12 |
| Rate for Payer: Adventist Health Commercial |
$70.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$243.76
|
| Rate for Payer: Cash Price |
$159.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$240.21
|
| Rate for Payer: Heritage Provider Network Senior |
$240.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.70
|
| Rate for Payer: Multiplan Commercial |
$266.12
|
|
|
DIAZEPAM 2 MG TABLET [2404]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 51079-284-20
|
| Hospital Charge Code |
1730080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
DIAZEPAM 2 MG TABLET [2404]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 51079-284-01
|
| Hospital Charge Code |
1730080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
