|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 6931591001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 5976210611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 5976210611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 0406123601
|
| 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: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 6068789011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0406123601
|
| 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 Non-Gatekeeper |
$0.14
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| 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 |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 6255949001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| 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 |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| 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 |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 6931591001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 6068789011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 6255949001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 6068789001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
IP
|
$70.25
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$52.69 |
| Rate for Payer: Adventist Health Commercial |
$14.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.24
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.53
|
| Rate for Payer: Heritage Provider Network Senior |
$32.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.56
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.26
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]
|
Facility
|
OP
|
$70.25
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$59.71 |
| Rate for Payer: Adventist Health Commercial |
$14.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.27
|
| Rate for Payer: Blue Shield of California Commercial |
$27.00
|
| Rate for Payer: Blue Shield of California EPN |
$27.00
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$59.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.53
|
| Rate for Payer: Heritage Provider Network Senior |
$32.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$33.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49.17
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.10
|
| Rate for Payer: TriValley Medical Group Senior |
$28.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.71
|
| Rate for Payer: Vantage Medical Group Senior |
$59.71
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
OP
|
$68.24
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Adventist Health Commercial |
$13.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.27
|
| Rate for Payer: Blue Shield of California Commercial |
$27.00
|
| Rate for Payer: Blue Shield of California EPN |
$27.00
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$58.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$58.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.60
|
| Rate for Payer: Heritage Provider Network Senior |
$31.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$32.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.77
|
| Rate for Payer: Multiplan Commercial |
$51.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.30
|
| Rate for Payer: TriValley Medical Group Senior |
$27.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58.00
|
| Rate for Payer: Vantage Medical Group Senior |
$58.00
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]
|
Facility
|
IP
|
$68.24
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$51.18 |
| Rate for Payer: Adventist Health Commercial |
$13.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.95
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.60
|
| Rate for Payer: Heritage Provider Network Senior |
$31.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.06
|
| Rate for Payer: Multiplan Commercial |
$51.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.59
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
OP
|
$117.19
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.21 |
| Max. Negotiated Rate |
$99.68 |
| Rate for Payer: Adventist Health Commercial |
$23.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$87.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$99.68
|
| Rate for Payer: Blue Shield of California Commercial |
$46.78
|
| Rate for Payer: Blue Shield of California EPN |
$46.78
|
| Rate for Payer: Cash Price |
$52.74
|
| Rate for Payer: Cash Price |
$52.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.26
|
| Rate for Payer: Heritage Provider Network Senior |
$54.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$55.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$82.03
|
| Rate for Payer: Multiplan Commercial |
$87.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$46.88
|
| Rate for Payer: TriValley Medical Group Senior |
$46.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.61
|
| Rate for Payer: Vantage Medical Group Senior |
$99.61
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
IP
|
$117.19
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.21 |
| Max. Negotiated Rate |
$87.89 |
| Rate for Payer: Adventist Health Commercial |
$23.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.47
|
| Rate for Payer: Cash Price |
$52.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.26
|
| Rate for Payer: Heritage Provider Network Senior |
$54.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.30
|
| Rate for Payer: Multiplan Commercial |
$87.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.80
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
IP
|
$114.94
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$86.20 |
| Rate for Payer: Adventist Health Commercial |
$22.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.02
|
| Rate for Payer: Cash Price |
$51.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.22
|
| Rate for Payer: Heritage Provider Network Senior |
$53.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.73
|
| Rate for Payer: Multiplan Commercial |
$86.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.06
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
OP
|
$114.94
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$99.68 |
| Rate for Payer: Adventist Health Commercial |
$22.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$99.68
|
| Rate for Payer: Blue Shield of California Commercial |
$46.78
|
| Rate for Payer: Blue Shield of California EPN |
$46.78
|
| Rate for Payer: Cash Price |
$51.72
|
| Rate for Payer: Cash Price |
$51.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.22
|
| Rate for Payer: Heritage Provider Network Senior |
$53.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.46
|
| Rate for Payer: Multiplan Commercial |
$86.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.98
|
| Rate for Payer: TriValley Medical Group Senior |
$45.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.70
|
| Rate for Payer: Vantage Medical Group Senior |
$97.70
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
IP
|
$152.14
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.54 |
| Max. Negotiated Rate |
$114.11 |
| Rate for Payer: Adventist Health Commercial |
$30.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$97.98
|
| Rate for Payer: Cash Price |
$68.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.44
|
| Rate for Payer: Heritage Provider Network Senior |
$70.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.03
|
| Rate for Payer: Multiplan Commercial |
$114.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.37
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
OP
|
$152.14
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.54 |
| Max. Negotiated Rate |
$129.32 |
| Rate for Payer: Adventist Health Commercial |
$30.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$94.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$129.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$83.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$114.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.80
|
| Rate for Payer: Blue Shield of California Commercial |
$116.18
|
| Rate for Payer: Blue Shield of California EPN |
$116.18
|
| Rate for Payer: Cash Price |
$68.46
|
| Rate for Payer: Cash Price |
$68.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$129.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.44
|
| Rate for Payer: Heritage Provider Network Senior |
$70.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$72.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$106.50
|
| Rate for Payer: Multiplan Commercial |
$114.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$60.86
|
| Rate for Payer: TriValley Medical Group Senior |
$60.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$129.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.32
|
| Rate for Payer: Vantage Medical Group Senior |
$129.32
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 6498013310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA 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 |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser 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 |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| 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
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6498013310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 6498013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.97
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 6498013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
