|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
IP
|
$0.23
|
|
|
Service Code
|
NDC 0406-1236-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 62559-490-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
IP
|
$0.56
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
1730124
|
|
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
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 59762-1061-1
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| 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 Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
OP
|
$0.23
|
|
|
Service Code
|
NDC 0406-1236-01
|
| Hospital Charge Code |
1730124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
OP
|
$0.56
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
1730124
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
OP
|
$80.39
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1721221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.55 |
| Max. Negotiated Rate |
$71.83 |
| Rate for Payer: Adventist Health Commercial |
$16.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$71.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$60.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.67
|
| Rate for Payer: Blue Shield of California Commercial |
$27.19
|
| Rate for Payer: Blue Shield of California EPN |
$27.19
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.33
|
| Rate for Payer: Dignity Health Senior |
$68.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.22
|
| Rate for Payer: Heritage Provider Network Senior |
$37.22
|
| Rate for Payer: IEHP Medi-Cal |
$49.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.10
|
| Rate for Payer: Multiplan Commercial |
$60.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.33
|
| Rate for Payer: Vantage Medical Group Senior |
$68.33
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
IP
|
$80.39
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1721221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.55 |
| Max. Negotiated Rate |
$60.29 |
| Rate for Payer: Adventist Health Commercial |
$16.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.23
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.42
|
| Rate for Payer: Heritage Provider Network Senior |
$54.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.10
|
| Rate for Payer: Multiplan Commercial |
$60.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.86
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
IP
|
$61.85
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1712559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$46.39 |
| Rate for Payer: Adventist Health Commercial |
$12.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.49
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.87
|
| Rate for Payer: Heritage Provider Network Senior |
$41.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.46
|
| Rate for Payer: Multiplan Commercial |
$46.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.66
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
OP
|
$61.85
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
1712559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$71.83 |
| Rate for Payer: Adventist Health Commercial |
$12.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$71.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$52.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$34.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$46.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.67
|
| Rate for Payer: Blue Shield of California Commercial |
$27.19
|
| Rate for Payer: Blue Shield of California EPN |
$27.19
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.57
|
| Rate for Payer: Dignity Health Senior |
$52.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.64
|
| Rate for Payer: Heritage Provider Network Senior |
$28.64
|
| Rate for Payer: IEHP Medi-Cal |
$49.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.46
|
| Rate for Payer: Multiplan Commercial |
$46.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.57
|
| Rate for Payer: Vantage Medical Group Senior |
$52.57
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
OP
|
$120.38
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
1726023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.79 |
| Max. Negotiated Rate |
$102.32 |
| Rate for Payer: Adventist Health Commercial |
$24.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$93.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$90.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.31
|
| Rate for Payer: Blue Shield of California EPN |
$45.31
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.32
|
| Rate for Payer: Dignity Health Senior |
$102.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.74
|
| Rate for Payer: Heritage Provider Network Senior |
$55.74
|
| Rate for Payer: IEHP Medi-Cal |
$66.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$58.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.10
|
| Rate for Payer: Multiplan Commercial |
$90.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.32
|
| Rate for Payer: Vantage Medical Group Senior |
$102.32
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
IP
|
$120.38
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
1726023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.79 |
| Max. Negotiated Rate |
$90.28 |
| Rate for Payer: Adventist Health Commercial |
$24.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.70
|
| Rate for Payer: Cash Price |
$54.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.50
|
| Rate for Payer: Heritage Provider Network Senior |
$81.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.10
|
| Rate for Payer: Multiplan Commercial |
$90.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.22
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
OP
|
$105.19
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
ERX186294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$93.18 |
| Rate for Payer: Adventist Health Commercial |
$21.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$93.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$89.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$78.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.31
|
| Rate for Payer: Blue Shield of California EPN |
$45.31
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.41
|
| Rate for Payer: Dignity Health Senior |
$89.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.70
|
| Rate for Payer: Heritage Provider Network Senior |
$48.70
|
| Rate for Payer: IEHP Medi-Cal |
$66.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.30
|
| Rate for Payer: Multiplan Commercial |
$78.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.41
|
| Rate for Payer: Vantage Medical Group Senior |
$89.41
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
IP
|
$105.19
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
ERX186294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$78.89 |
| Rate for Payer: Adventist Health Commercial |
$21.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.27
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.21
|
| Rate for Payer: Heritage Provider Network Senior |
$71.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.30
|
| Rate for Payer: Multiplan Commercial |
$78.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.14
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
1710561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
1710561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
OP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
1710594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Senior |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
IP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
1710594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
ERX4080265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| 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 |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
ERX4080265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| 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 |
$0.05
|
|
|
Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
|
Facility
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 63075
|
| Min. Negotiated Rate |
$302.59 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: IEHP Medi-Cal |
$302.59
|
| Rate for Payer: IEHP Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
IP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
OP
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$3.48
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: Dignity Health Senior |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
IP
|
$5.61
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Senior |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
OP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
1710215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Senior |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
