|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 24385-441-64
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care 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 |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 24385-441-64
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.12
|
| 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
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 4116700607
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
NDC 67877-753-60
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
NDC 67877-753-60
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 67877-754-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.09 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Senior |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
OP
|
$4.12
|
|
|
Service Code
|
NDC 67877-754-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.09
|
| Rate for Payer: Blue Shield of California Commercial |
$2.51
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.50
|
| Rate for Payer: Dignity Health Senior |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Senior |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Senior |
$1.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
OP
|
$20.63
|
|
|
Service Code
|
NDC 0904-7145-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$17.54 |
| Rate for Payer: Adventist Health Commercial |
$4.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.47
|
| Rate for Payer: Blue Shield of California Commercial |
$12.58
|
| Rate for Payer: Blue Shield of California EPN |
$10.07
|
| Rate for Payer: Cash Price |
$11.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.54
|
| Rate for Payer: Dignity Health Senior |
$17.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.77
|
| Rate for Payer: Heritage Provider Network Senior |
$12.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.44
|
| Rate for Payer: Multiplan Commercial |
$15.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.25
|
| Rate for Payer: TriValley Medical Group Senior |
$8.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.54
|
| Rate for Payer: Vantage Medical Group Senior |
$17.54
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
IP
|
$20.63
|
|
|
Service Code
|
NDC 0904-7145-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$15.47 |
| Rate for Payer: Adventist Health Commercial |
$4.13
|
| Rate for Payer: Cash Price |
$11.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.97
|
| Rate for Payer: Heritage Provider Network Senior |
$13.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.16
|
| Rate for Payer: Multiplan Commercial |
$15.47
|
|
|
DRONEDARONE 400 MG TABLET [98329]
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 0024-4142-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Adventist Health Commercial |
$3.24
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.97
|
| Rate for Payer: Heritage Provider Network Senior |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$12.15
|
|
|
DRONEDARONE 400 MG TABLET [98329]
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 0024-4142-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Adventist Health Commercial |
$3.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.15
|
| Rate for Payer: Blue Shield of California Commercial |
$9.88
|
| Rate for Payer: Blue Shield of California EPN |
$7.91
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.77
|
| Rate for Payer: Dignity Health Senior |
$13.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.03
|
| Rate for Payer: Heritage Provider Network Senior |
$10.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.34
|
| Rate for Payer: Multiplan Commercial |
$12.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.48
|
| Rate for Payer: TriValley Medical Group Senior |
$6.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.77
|
| Rate for Payer: Vantage Medical Group Senior |
$13.77
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.11
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$25.08 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.08
|
| Rate for Payer: Blue Shield of California Commercial |
$10.85
|
| Rate for Payer: Blue Shield of California EPN |
$10.85
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.42
|
| Rate for Payer: Dignity Health Senior |
$5.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.47
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.55
|
| Rate for Payer: TriValley Medical Group Senior |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Vantage Medical Group Senior |
$5.42
|
|
|
DROXIDOPA 100 MG CAPSULE [206920]
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 0054-0532-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
DROXIDOPA 100 MG CAPSULE [206920]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 0054-0532-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.41
|
| Rate for Payer: Dignity Health Senior |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Vantage Medical Group Senior |
$1.41
|
|
|
DT10B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5548
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT10BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5549
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT11B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5550
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT11BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5551
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT12B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5552
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT12BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5553
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT13B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5554
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DT13BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5555
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
