|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$3.79
|
|
|
Service Code
|
NDC 6846285101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.44
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.57
|
| Rate for Payer: Heritage Provider Network Senior |
$2.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$2.84
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 5107992501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.01
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$3.48
|
|
|
Service Code
|
NDC 0378609001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Senior |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.96
|
| Rate for Payer: Vantage Medical Group Senior |
$2.96
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 5107992520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.01
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 5107992520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.28
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.27
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.97
|
| Rate for Payer: Vantage Medical Group Senior |
$3.97
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$3.79
|
|
|
Service Code
|
NDC 6846285101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.90
|
| Rate for Payer: Blue Shield of California Commercial |
$2.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Senior |
$2.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$2.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.52
|
| Rate for Payer: TriValley Medical Group Senior |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.22
|
| Rate for Payer: Vantage Medical Group Senior |
$3.22
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 5107992501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.28
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.27
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.97
|
| Rate for Payer: Vantage Medical Group Senior |
$3.97
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 0378609001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.24
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.36
|
| Rate for Payer: Heritage Provider Network Senior |
$2.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 9994080264
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 9994080264
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DILTIAZEM TOPICAL GEL 2 % (COMPOUNDED) [4081048]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 9994081048
|
| 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: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DILTIAZEM TOPICAL GEL 2 % (COMPOUNDED) [4081048]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 9994081048
|
| 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 Non-Gatekeeper |
$0.19
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| 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 |
$0.14
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
OP
|
$15.77
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.13
|
| Rate for Payer: Blue Shield of California Commercial |
$11.76
|
| Rate for Payer: Blue Shield of California EPN |
$11.76
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Senior |
$7.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.04
|
| Rate for Payer: Multiplan Commercial |
$11.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.31
|
| Rate for Payer: TriValley Medical Group Senior |
$6.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.40
|
| Rate for Payer: Vantage Medical Group Senior |
$13.40
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]
|
Facility
|
IP
|
$15.77
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$11.83 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.16
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Senior |
$7.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$11.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.22
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
IP
|
$686.63
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.28 |
| Max. Negotiated Rate |
$514.97 |
| Rate for Payer: Adventist Health Commercial |
$137.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$442.19
|
| Rate for Payer: Cash Price |
$308.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$315.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$370.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$317.91
|
| Rate for Payer: Heritage Provider Network Senior |
$317.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$124.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$171.66
|
| Rate for Payer: Multiplan Commercial |
$514.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$227.34
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
OP
|
$686.63
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.28 |
| Max. Negotiated Rate |
$583.64 |
| Rate for Payer: Adventist Health Commercial |
$137.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$424.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$583.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$377.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$514.97
|
| Rate for Payer: Blue Shield of California Commercial |
$418.84
|
| Rate for Payer: Blue Shield of California EPN |
$335.08
|
| Rate for Payer: Cash Price |
$308.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$315.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$583.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$583.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$583.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$439.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$317.91
|
| Rate for Payer: Heritage Provider Network Senior |
$317.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$327.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$124.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$171.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$480.64
|
| Rate for Payer: Multiplan Commercial |
$514.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$274.65
|
| Rate for Payer: TriValley Medical Group Senior |
$274.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$227.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$583.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$583.64
|
| Rate for Payer: Vantage Medical Group Senior |
$583.64
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
|
IP
|
$5,023.91
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$909.33 |
| Max. Negotiated Rate |
$3,767.93 |
| Rate for Payer: Adventist Health Commercial |
$1,004.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,235.40
|
| Rate for Payer: Cash Price |
$2,260.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,311.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,712.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,326.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2,326.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$909.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,255.98
|
| Rate for Payer: Multiplan Commercial |
$3,767.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,815.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,663.42
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION [209941]
|
Facility
|
OP
|
$5,023.91
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$909.33 |
| Max. Negotiated Rate |
$4,270.32 |
| Rate for Payer: Cigna of CA HMO/PPO |
$2,311.00
|
| Rate for Payer: Adventist Health Commercial |
$1,004.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,104.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,270.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,763.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,767.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3,064.59
|
| Rate for Payer: Blue Shield of California EPN |
$2,451.67
|
| Rate for Payer: Cash Price |
$2,260.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,270.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,270.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,270.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,215.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,326.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2,326.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,396.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$909.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,255.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,516.74
|
| Rate for Payer: Multiplan Commercial |
$3,767.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,009.56
|
| Rate for Payer: TriValley Medical Group Senior |
$2,009.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,815.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,663.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,270.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,270.32
|
| Rate for Payer: Vantage Medical Group Senior |
$4,270.32
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0121048900
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| 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 |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9999251100
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0121048905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| 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 |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0121048905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9999251100
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| 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 |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
