|
DESMOPRESSIN 0.2 MG TABLET [16053]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 60505-0258-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.84
|
| Rate for Payer: Dignity Health Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]
|
Facility
|
IP
|
$47.28
|
|
|
Service Code
|
NDC 24208-342-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Adventist Health Commercial |
$9.46
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.01
|
| Rate for Payer: Heritage Provider Network Senior |
$32.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.82
|
| Rate for Payer: Multiplan Commercial |
$35.46
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]
|
Facility
|
OP
|
$47.28
|
|
|
Service Code
|
NDC 24208-342-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Adventist Health Commercial |
$9.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.46
|
| Rate for Payer: Blue Shield of California Commercial |
$28.84
|
| Rate for Payer: Blue Shield of California EPN |
$23.07
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.19
|
| Rate for Payer: Dignity Health Senior |
$40.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.27
|
| Rate for Payer: Heritage Provider Network Senior |
$29.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.10
|
| Rate for Payer: Multiplan Commercial |
$35.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.91
|
| Rate for Payer: TriValley Medical Group Senior |
$18.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.19
|
| Rate for Payer: Vantage Medical Group Senior |
$40.19
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED) [21135]
|
Facility
|
IP
|
$29.55
|
|
|
Service Code
|
NDC 47335-788-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$22.16 |
| Rate for Payer: Adventist Health Commercial |
$5.91
|
| Rate for Payer: Cash Price |
$16.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Senior |
$20.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.39
|
| Rate for Payer: Multiplan Commercial |
$22.16
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED) [21135]
|
Facility
|
OP
|
$29.55
|
|
|
Service Code
|
NDC 47335-788-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Adventist Health Commercial |
$5.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.16
|
| Rate for Payer: Blue Shield of California Commercial |
$18.03
|
| Rate for Payer: Blue Shield of California EPN |
$14.42
|
| Rate for Payer: Cash Price |
$16.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.12
|
| Rate for Payer: Dignity Health Senior |
$25.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.29
|
| Rate for Payer: Heritage Provider Network Senior |
$18.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.68
|
| Rate for Payer: Multiplan Commercial |
$22.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.82
|
| Rate for Payer: TriValley Medical Group Senior |
$11.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.12
|
| Rate for Payer: Vantage Medical Group Senior |
$25.12
|
|
|
DESMOPRESSIN 25 MCG 1/4 TAB [4080522]
|
Facility
|
OP
|
$3.02
|
|
|
Service Code
|
NDC 9994-0805-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.57
|
| Rate for Payer: Dignity Health Senior |
$2.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Senior |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.11
|
| Rate for Payer: Multiplan Commercial |
$2.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.57
|
| Rate for Payer: Vantage Medical Group Senior |
$2.57
|
|
|
DESMOPRESSIN 25 MCG 1/4 TAB [4080522]
|
Facility
|
IP
|
$3.02
|
|
|
Service Code
|
NDC 9994-0805-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.27
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
|
IP
|
$47.40
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$35.55 |
| Rate for Payer: Adventist Health Commercial |
$9.48
|
| Rate for Payer: Adventist Health Commercial |
$12.60
|
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Adventist Health Commercial |
$7.71
|
| Rate for Payer: Cash Price |
$21.21
|
| Rate for Payer: Cash Price |
$26.07
|
| Rate for Payer: Cash Price |
$34.65
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$29.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$17.86
|
| Rate for Payer: Heritage Provider Network Senior |
$21.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$35.55
|
| Rate for Payer: Multiplan Commercial |
$28.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.36
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$47.25 |
| Rate for Payer: Adventist Health Commercial |
$12.60
|
| Rate for Payer: Adventist Health Commercial |
$9.48
|
| Rate for Payer: Adventist Health Commercial |
$7.71
|
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.25
|
| Rate for Payer: Blue Shield of California Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California EPN |
$9.95
|
| Rate for Payer: Blue Shield of California EPN |
$9.95
|
| Rate for Payer: Blue Shield of California EPN |
$9.95
|
| Rate for Payer: Blue Shield of California EPN |
$9.95
|
| Rate for Payer: Cash Price |
$34.65
|
| Rate for Payer: Cash Price |
$26.07
|
| Rate for Payer: Cash Price |
$21.21
|
| Rate for Payer: Cash Price |
$26.07
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cash Price |
$21.21
|
| Rate for Payer: Cash Price |
$34.65
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.28
|
| Rate for Payer: Dignity Health Senior |
$4.28
|
| Rate for Payer: Dignity Health Senior |
$4.28
|
| Rate for Payer: Dignity Health Senior |
$4.28
|
| Rate for Payer: Dignity Health Senior |
$4.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.89
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.89
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.89
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$29.17
|
| Rate for Payer: Heritage Provider Network Senior |
$17.86
|
| Rate for Payer: Heritage Provider Network Senior |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$21.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$30.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.90
|
| Rate for Payer: Multiplan Commercial |
$28.93
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$35.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.20
|
| Rate for Payer: TriValley Medical Group Senior |
$7.68
|
| Rate for Payer: TriValley Medical Group Senior |
$15.43
|
| Rate for Payer: TriValley Medical Group Senior |
$25.20
|
| Rate for Payer: TriValley Medical Group Senior |
$18.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.28
|
|
|
DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 9994-0804-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 9994-0804-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| 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 Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 51672-1281-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Senior |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 51672-1281-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 51672-1281-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Senior |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 51672-1281-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
NDC 45802-495-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
OP
|
$3.29
|
|
|
Service Code
|
NDC 45802-495-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.80
|
| Rate for Payer: Dignity Health Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.30
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Senior |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: Vantage Medical Group Senior |
$2.80
|
|
|
DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]
|
Facility
|
OP
|
$1.17
|
|
|
Service Code
|
NDC 51991-006-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Senior |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]
|
Facility
|
IP
|
$1.17
|
|
|
Service Code
|
NDC 51991-006-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.88
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 0054-0400-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 0054-0400-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.14 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.86
|
| Rate for Payer: Heritage Provider Network Senior |
$11.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.14
|
| Rate for Payer: Blue Shield of California Commercial |
$10.69
|
| Rate for Payer: Blue Shield of California EPN |
$8.55
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.89
|
| Rate for Payer: Dignity Health Senior |
$14.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.84
|
| Rate for Payer: Heritage Provider Network Senior |
$10.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.26
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.01
|
| Rate for Payer: TriValley Medical Group Senior |
$7.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.89
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.14 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.86
|
| Rate for Payer: Heritage Provider Network Senior |
$11.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 0054-0400-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.08
|
| Rate for Payer: Dignity Health Senior |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Senior |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Vantage Medical Group Senior |
$1.08
|
|
