|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
NDC 4580249535
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.30
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.31
|
| Rate for Payer: TriValley Medical Group Senior |
$1.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2.79
|
|
|
DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 46922
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,569.96 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,354.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,926.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,569.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,354.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,926.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,569.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,569.96
|
| Rate for Payer: Heritage Provider Network Senior |
$4,391.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,569.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6,782.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,105.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4,783.75
|
| Rate for Payer: Multiplan WC |
$5,551.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,926.96
|
| Rate for Payer: TriValley Medical Group Senior |
$3,926.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,354.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,926.96
|
| Rate for Payer: Vantage Medical Group Senior |
$3,569.96
|
|
|
DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]
|
Facility
|
IP
|
$1.17
|
|
|
Service Code
|
NDC 5199100633
|
| 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: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.53
|
| 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 Foundation Hospitals 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 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]
|
Facility
|
IP
|
$1.17
|
|
|
Service Code
|
NDC 6818060406
|
| 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: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.53
|
| 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 Foundation Hospitals 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 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]
|
Facility
|
OP
|
$1.17
|
|
|
Service Code
|
NDC 5199100633
|
| 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 Non-Gatekeeper |
$0.72
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| 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 |
$0.53
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$1.17
|
|
|
Service Code
|
NDC 6818060406
|
| 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 Non-Gatekeeper |
$0.72
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| 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 |
$0.53
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 0054040013
|
| 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 Non-Gatekeeper |
$0.78
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| 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 |
$0.57
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008121130
|
| 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 Non-Gatekeeper |
$10.83
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$8.76
|
| 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 |
$7.88
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$8.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$1.27
|
|
|
Service Code
|
NDC 0054040022
|
| 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: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 Foundation Hospitals 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 0054040013
|
| 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: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 Foundation Hospitals 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
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 5976212113
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008121114
|
| 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 Non-Gatekeeper |
$10.83
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$8.76
|
| 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 |
$7.88
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$8.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 0054040022
|
| 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 Non-Gatekeeper |
$0.78
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| 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 |
$0.57
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008121114
|
| 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: Aetna of CA Non-Gatekeeper |
$11.28
|
| Rate for Payer: Cash Price |
$7.88
|
| 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 Foundation Hospitals 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
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 5976212113
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008121130
|
| 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: Aetna of CA Non-Gatekeeper |
$11.28
|
| Rate for Payer: Cash Price |
$7.88
|
| 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 Foundation Hospitals Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
|
|
DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]
|
Facility
|
OP
|
$38.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$32.64 |
| Rate for Payer: Adventist Health Commercial |
$7.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$32.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.80
|
| Rate for Payer: Blue Shield of California Commercial |
$23.42
|
| Rate for Payer: Blue Shield of California EPN |
$18.74
|
| Rate for Payer: Cash Price |
$17.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.78
|
| Rate for Payer: Heritage Provider Network Senior |
$17.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$18.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26.88
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.36
|
| Rate for Payer: TriValley Medical Group Senior |
$15.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: Vantage Medical Group Senior |
$32.64
|
|
|
DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]
|
Facility
|
IP
|
$38.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Adventist Health Commercial |
$7.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Cash Price |
$17.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.78
|
| Rate for Payer: Heritage Provider Network Senior |
$17.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.71
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
|
OP
|
$12.94
|
|
|
Service Code
|
NDC 2420872002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Adventist Health Commercial |
$2.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.47
|
| Rate for Payer: Blue Shield of California Commercial |
$7.89
|
| Rate for Payer: Blue Shield of California EPN |
$6.31
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.01
|
| Rate for Payer: Heritage Provider Network Senior |
$8.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.06
|
| Rate for Payer: Multiplan Commercial |
$9.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Vantage Medical Group Senior |
$11.00
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
|
IP
|
$12.94
|
|
|
Service Code
|
NDC 2420872002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.71 |
| Rate for Payer: Adventist Health Commercial |
$2.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.33
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.76
|
| Rate for Payer: Heritage Provider Network Senior |
$8.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: Multiplan Commercial |
$9.71
|
|
|
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION [2320]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
|
|
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION [2320]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
DEXAMETHASONE 0.5 MG TABLET [2322]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
DEXAMETHASONE 0.5 MG TABLET [2322]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals 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: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
|
|
DEXAMETHASONE 0.7 MG INTRAVITREAL IMPLANT [99461]
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS J7312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$304.08 |
| Max. Negotiated Rate |
$1,260.00 |
| Rate for Payer: Adventist Health Commercial |
$336.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,081.92
|
| Rate for Payer: Cash Price |
$756.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$772.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$907.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$777.84
|
| Rate for Payer: Heritage Provider Network Senior |
$777.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$304.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$420.00
|
| Rate for Payer: Multiplan Commercial |
$1,260.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$606.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$556.25
|
|
