|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$32,145.87
|
|
|
Service Code
|
APR-DRG 1312
|
| Min. Negotiated Rate |
$25,674.40 |
| Max. Negotiated Rate |
$32,145.87 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25,674.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32,145.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28,762.10
|
|
|
CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 52310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$495.36 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,032.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,957.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,688.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,032.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,957.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,688.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,436.16
|
| Rate for Payer: EPIC Health Plan Senior |
$2,957.44
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,409.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$495.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,688.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$560.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,764.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,387.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,602.70
|
| Rate for Payer: Multiplan WC |
$4,147.14
|
| Rate for Payer: Prime Health Services WC |
$4,104.83
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,688.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,032.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,957.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2,688.58
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$0.94
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$0.88
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
|
IP
|
$1.10
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
|
IP
|
$44.73
|
|
|
Service Code
|
HCPCS J0850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Adventist Health Commercial |
$8.95
|
| Rate for Payer: Blue Shield of California Commercial |
$22.68
|
| Rate for Payer: Blue Shield of California Commercial |
$34.40
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: Cigna of CA HMO |
$31.31
|
| Rate for Payer: Cigna of CA PPO |
$31.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$31.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.89
|
| Rate for Payer: EPIC Health Plan Senior |
$17.89
|
| Rate for Payer: Galaxy Health WC |
$38.02
|
| Rate for Payer: Global Benefits Group Commercial |
$26.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$28.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.74
|
| Rate for Payer: Multiplan Commercial |
$35.78
|
| Rate for Payer: Networks By Design Commercial |
$22.36
|
| Rate for Payer: Prime Health Services Commercial |
$38.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.79
|
| Rate for Payer: United Healthcare All Other HMO |
$16.34
|
| Rate for Payer: United Healthcare HMO Rider |
$15.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.65
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
|
OP
|
$44.73
|
|
|
Service Code
|
HCPCS J0850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$11,396.59 |
| Rate for Payer: Adventist Health Commercial |
$8.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,396.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,323.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,044.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,044.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,723.48
|
| Rate for Payer: Blue Shield of California Commercial |
$2,108.22
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: Cigna of CA HMO |
$31.31
|
| Rate for Payer: Cigna of CA PPO |
$31.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,323.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,044.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,044.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$31.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,067.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2,044.70
|
| Rate for Payer: Galaxy Health WC |
$38.02
|
| Rate for Payer: Global Benefits Group Commercial |
$26.84
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,048.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,858.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,858.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$28.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3,435.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,602.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,342.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,490.82
|
| Rate for Payer: Multiplan Commercial |
$35.78
|
| Rate for Payer: Networks By Design Commercial |
$22.36
|
| Rate for Payer: Prime Health Services Commercial |
$38.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$26.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$26.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.79
|
| Rate for Payer: United Healthcare All Other HMO |
$16.34
|
| Rate for Payer: United Healthcare HMO Rider |
$15.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.65
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,858.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,323.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,044.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2,044.70
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597010854
|
| 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 |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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 110 MG CAPSULE [212609]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597010854
|
| 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 |
$2.55
|
| Rate for Payer: Cash Price |
$1.79
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597036055
|
| 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 |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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
|
$3.97
|
|
|
Service Code
|
NDC 0597036082
|
| 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 |
$2.55
|
| Rate for Payer: Cash Price |
$1.79
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 6233263606
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 3172262260
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.16
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597036055
|
| 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 |
$2.55
|
| Rate for Payer: Cash Price |
$1.79
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 3172262260
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1.38
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 6233263606
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597036082
|
| 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 |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 6068774411
|
| 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 |
$11.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.29
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.48
|
| 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 6068774411
|
| 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 |
$9.22
|
| Rate for Payer: Cash Price |
$6.47
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.48
|
| 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 6068774421
|
| 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 |
$11.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.29
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.48
|
| 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
|
$3.97
|
|
|
Service Code
|
NDC 0597035556
|
| 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 |
$2.55
|
| Rate for Payer: Cash Price |
$1.79
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 6068774421
|
| 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 |
$9.22
|
| Rate for Payer: Cash Price |
$6.47
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.48
|
| 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
|
$3.97
|
|
|
Service Code
|
NDC 0597035556
|
| 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 |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.34
|
| 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
|
|
|
DABRAFENIB 10 MG TABLET FOR ORAL SUSPENSION [237957]
|
Facility
|
OP
|
$26.12
|
|
|
Service Code
|
NDC 0078115421
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$22.20 |
| Rate for Payer: Adventist Health Commercial |
$5.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.76
|
| Rate for Payer: Cash Price |
$11.75
|
| Rate for Payer: Cigna of CA HMO |
$18.28
|
| Rate for Payer: Cigna of CA PPO |
$18.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.45
|
| Rate for Payer: EPIC Health Plan Senior |
$10.45
|
| Rate for Payer: Galaxy Health WC |
$22.20
|
| Rate for Payer: Global Benefits Group Commercial |
$15.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.28
|
| Rate for Payer: Multiplan Commercial |
$20.90
|
| Rate for Payer: Networks By Design Commercial |
$16.98
|
| Rate for Payer: Prime Health Services Commercial |
$22.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.06
|
| Rate for Payer: United Healthcare All Other HMO |
$13.06
|
| Rate for Payer: United Healthcare HMO Rider |
$13.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.20
|
| Rate for Payer: Vantage Medical Group Senior |
$22.20
|
|
|
DABRAFENIB 10 MG TABLET FOR ORAL SUSPENSION [237957]
|
Facility
|
IP
|
$26.12
|
|
|
Service Code
|
NDC 0078115421
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$22.20 |
| Rate for Payer: Adventist Health Commercial |
$5.22
|
| Rate for Payer: Blue Shield of California Commercial |
$13.24
|
| Rate for Payer: Blue Shield of California Commercial |
$20.09
|
| Rate for Payer: Cash Price |
$11.75
|
| Rate for Payer: Cigna of CA HMO |
$18.28
|
| Rate for Payer: Cigna of CA PPO |
$18.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.45
|
| Rate for Payer: EPIC Health Plan Senior |
$10.45
|
| Rate for Payer: Galaxy Health WC |
$22.20
|
| Rate for Payer: Global Benefits Group Commercial |
$15.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.27
|
| Rate for Payer: Multiplan Commercial |
$20.90
|
| Rate for Payer: Networks By Design Commercial |
$16.98
|
| Rate for Payer: Prime Health Services Commercial |
$22.20
|
|
|
DABRAFENIB 50 MG CAPSULE [202199]
|
Facility
|
IP
|
$130.62
|
|
|
Service Code
|
NDC 0078068266
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.12 |
| Max. Negotiated Rate |
$111.03 |
| Rate for Payer: Adventist Health Commercial |
$26.12
|
| Rate for Payer: Blue Shield of California Commercial |
$100.45
|
| Rate for Payer: Blue Shield of California Commercial |
$66.22
|
| Rate for Payer: Cash Price |
$58.78
|
| Rate for Payer: Cigna of CA HMO |
$91.43
|
| Rate for Payer: Cigna of CA PPO |
$91.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$91.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.25
|
| Rate for Payer: EPIC Health Plan Senior |
$52.25
|
| Rate for Payer: Galaxy Health WC |
$111.03
|
| Rate for Payer: Global Benefits Group Commercial |
$78.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$82.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$77.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.35
|
| Rate for Payer: Multiplan Commercial |
$104.50
|
| Rate for Payer: Networks By Design Commercial |
$84.90
|
| Rate for Payer: Prime Health Services Commercial |
$111.03
|
|
