|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 31722-622-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62332-636-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 31722-622-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.47
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62332-636-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.44
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California Commercial |
$10.61
|
| Rate for Payer: Blue Shield of California EPN |
$6.98
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.82
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.18
|
| Rate for Payer: United Healthcare All Other HMO |
$7.18
|
| Rate for Payer: United Healthcare HMO Rider |
$7.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California Commercial |
$10.61
|
| Rate for Payer: Blue Shield of California EPN |
$6.98
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.82
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.18
|
| Rate for Payer: United Healthcare All Other HMO |
$7.18
|
| Rate for Payer: United Healthcare HMO Rider |
$7.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.44
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
IP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$12.64 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Blue Shield of California Commercial |
$10.97
|
| Rate for Payer: Blue Shield of California EPN |
$7.23
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cigna of CA HMO |
$10.41
|
| Rate for Payer: Cigna of CA PPO |
$10.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$12.64
|
| Rate for Payer: Global Benefits Group Commercial |
$8.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
| Rate for Payer: Multiplan Commercial |
$11.90
|
| Rate for Payer: Networks By Design Commercial |
$7.43
|
| Rate for Payer: Prime Health Services Commercial |
$12.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.87
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
OP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$16.30 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.30
|
| Rate for Payer: Blue Shield of California Commercial |
$7.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.20
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cigna of CA HMO |
$10.41
|
| Rate for Payer: Cigna of CA PPO |
$10.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$12.64
|
| Rate for Payer: Global Benefits Group Commercial |
$8.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.41
|
| Rate for Payer: Multiplan Commercial |
$11.90
|
| Rate for Payer: Networks By Design Commercial |
$7.43
|
| Rate for Payer: Prime Health Services Commercial |
$12.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.64
|
| Rate for Payer: Vantage Medical Group Senior |
$12.64
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
OP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$16.30 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.30
|
| Rate for Payer: Blue Shield of California Commercial |
$7.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.20
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$11.52
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
IP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$10.63
|
| Rate for Payer: Blue Shield of California EPN |
$7.00
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$11.52
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Blue Shield of California Commercial |
$487.38
|
| Rate for Payer: Blue Shield of California EPN |
$320.95
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$528.32
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$433.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$405.55
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$528.32
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$330.20
|
| Rate for Payer: United Healthcare All Other HMO |
$330.20
|
| Rate for Payer: United Healthcare HMO Rider |
$330.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$433.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$405.55
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$528.32
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$330.20
|
| Rate for Payer: United Healthcare All Other HMO |
$330.20
|
| Rate for Payer: United Healthcare HMO Rider |
$330.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Blue Shield of California Commercial |
$487.38
|
| Rate for Payer: Blue Shield of California EPN |
$320.95
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$528.32
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Multiplan Commercial |
$528.32
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$433.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$405.55
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$330.20
|
| Rate for Payer: United Healthcare All Other HMO |
$330.20
|
| Rate for Payer: United Healthcare HMO Rider |
$330.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Blue Shield of California Commercial |
$487.38
|
| Rate for Payer: Blue Shield of California EPN |
$320.95
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$528.32
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
OP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.00 |
| Max. Negotiated Rate |
$2,003.37 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$580.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$454.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$333.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$302.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,003.37
|
| Rate for Payer: Blue Shield of California Commercial |
$885.00
|
| Rate for Payer: Blue Shield of California EPN |
$885.00
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$333.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$333.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$408.94
|
| Rate for Payer: EPIC Health Plan Senior |
$302.92
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$288.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$302.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$617.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$302.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$381.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$405.91
|
| Rate for Payer: Multiplan Commercial |
$708.00
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$531.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$531.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$332.14
|
| Rate for Payer: United Healthcare All Other HMO |
$323.29
|
| Rate for Payer: United Healthcare HMO Rider |
$316.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$289.84
|
| Rate for Payer: Upland Medical Group Pediatric |
$302.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$333.21
|
| Rate for Payer: Vantage Medical Group Senior |
$333.21
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
IP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.00 |
| Max. Negotiated Rate |
$752.25 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Blue Shield of California Commercial |
$653.13
|
| Rate for Payer: Blue Shield of California EPN |
$430.11
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$354.00
|
| Rate for Payer: EPIC Health Plan Senior |
$354.00
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$547.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$708.00
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$332.14
|
| Rate for Payer: United Healthcare All Other HMO |
$323.29
|
| Rate for Payer: United Healthcare HMO Rider |
$316.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$289.84
|
|
