|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 59651-119-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO |
$0.80
|
| Rate for Payer: United Healthcare HMO Rider |
$0.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 59762-0038-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.43
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 72205-040-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 47335-062-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 47335-062-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO |
$0.96
|
| Rate for Payer: United Healthcare HMO Rider |
$0.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 59651-119-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 69452-132-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 72205-040-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 59762-0038-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.07
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$5.70
|
|
|
Service Code
|
NDC 0069-5810-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.50
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Cigna of CA HMO |
$3.99
|
| Rate for Payer: Cigna of CA PPO |
$3.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: EPIC Health Plan Senior |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.84
|
| Rate for Payer: Global Benefits Group Commercial |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.99
|
| Rate for Payer: Multiplan Commercial |
$4.56
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.85
|
| Rate for Payer: United Healthcare All Other HMO |
$2.85
|
| Rate for Payer: United Healthcare HMO Rider |
$2.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.84
|
| Rate for Payer: Vantage Medical Group Senior |
$4.84
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 69452-132-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$5.70
|
|
|
Service Code
|
NDC 0069-5810-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California Commercial |
$4.21
|
| Rate for Payer: Blue Shield of California EPN |
$2.77
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Cigna of CA HMO |
$3.99
|
| Rate for Payer: Cigna of CA PPO |
$3.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: EPIC Health Plan Senior |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.84
|
| Rate for Payer: Global Benefits Group Commercial |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.56
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.84
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 72205-041-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$13.43
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$11.42 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California Commercial |
$9.91
|
| Rate for Payer: Blue Shield of California EPN |
$6.53
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO |
$9.40
|
| Rate for Payer: Cigna of CA PPO |
$9.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.37
|
| Rate for Payer: EPIC Health Plan Senior |
$5.37
|
| Rate for Payer: Galaxy Health WC |
$11.42
|
| Rate for Payer: Global Benefits Group Commercial |
$8.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$10.74
|
| Rate for Payer: Networks By Design Commercial |
$8.73
|
| Rate for Payer: Prime Health Services Commercial |
$11.42
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$6.32
|
|
|
Service Code
|
NDC 0904-6683-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.37 |
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.53
|
| Rate for Payer: EPIC Health Plan Senior |
$2.53
|
| Rate for Payer: Galaxy Health WC |
$5.37
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: Networks By Design Commercial |
$4.11
|
| Rate for Payer: Prime Health Services Commercial |
$5.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.16
|
| Rate for Payer: United Healthcare All Other HMO |
$3.16
|
| Rate for Payer: United Healthcare HMO Rider |
$3.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.37
|
| Rate for Payer: Vantage Medical Group Senior |
$5.37
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 72205-041-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$13.43
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$11.42 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.25
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO |
$9.40
|
| Rate for Payer: Cigna of CA PPO |
$9.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.37
|
| Rate for Payer: EPIC Health Plan Senior |
$5.37
|
| Rate for Payer: Galaxy Health WC |
$11.42
|
| Rate for Payer: Global Benefits Group Commercial |
$8.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.40
|
| Rate for Payer: Multiplan Commercial |
$10.74
|
| Rate for Payer: Networks By Design Commercial |
$8.73
|
| Rate for Payer: Prime Health Services Commercial |
$11.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.71
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.42
|
| Rate for Payer: Vantage Medical Group Senior |
$11.42
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$6.32
|
|
|
Service Code
|
NDC 0904-6683-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.37 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.53
|
| Rate for Payer: EPIC Health Plan Senior |
$2.53
|
| Rate for Payer: Galaxy Health WC |
$5.37
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: Networks By Design Commercial |
$4.11
|
| Rate for Payer: Prime Health Services Commercial |
$5.37
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
IP
|
$146.11
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.22 |
| Max. Negotiated Rate |
$124.19 |
| Rate for Payer: Adventist Health Commercial |
$29.22
|
| Rate for Payer: Blue Shield of California Commercial |
$107.83
|
| Rate for Payer: Blue Shield of California EPN |
$71.01
|
| Rate for Payer: Cash Price |
$80.36
|
| Rate for Payer: Cigna of CA HMO |
$102.28
|
| Rate for Payer: Cigna of CA PPO |
$102.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.44
|
| Rate for Payer: EPIC Health Plan Senior |
$58.44
|
| Rate for Payer: Galaxy Health WC |
$124.19
|
| Rate for Payer: Global Benefits Group Commercial |
$87.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.07
|
| Rate for Payer: Multiplan Commercial |
$116.89
|
| Rate for Payer: Networks By Design Commercial |
$94.97
|
| Rate for Payer: Prime Health Services Commercial |
$124.19
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
OP
|
$146.11
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.22 |
| Max. Negotiated Rate |
$124.19 |
| Rate for Payer: Adventist Health Commercial |
$29.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$95.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$124.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$109.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$89.73
|
| Rate for Payer: Cash Price |
$80.36
|
| Rate for Payer: Cigna of CA HMO |
$102.28
|
| Rate for Payer: Cigna of CA PPO |
$102.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$124.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$124.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.44
|
| Rate for Payer: EPIC Health Plan Senior |
$58.44
|
| Rate for Payer: Galaxy Health WC |
$124.19
|
| Rate for Payer: Global Benefits Group Commercial |
$87.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$102.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$102.28
|
| Rate for Payer: Multiplan Commercial |
$116.89
|
| Rate for Payer: Networks By Design Commercial |
$94.97
|
| Rate for Payer: Prime Health Services Commercial |
$124.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$87.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$87.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$73.06
|
| Rate for Payer: United Healthcare All Other HMO |
$73.06
|
| Rate for Payer: United Healthcare HMO Rider |
$73.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$73.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$124.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.19
|
| Rate for Payer: Vantage Medical Group Senior |
$124.19
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
IP
|
$93.01
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Adventist Health Commercial |
$18.60
|
| Rate for Payer: Blue Shield of California Commercial |
$68.64
|
| Rate for Payer: Blue Shield of California EPN |
$45.20
|
| Rate for Payer: Cash Price |
$51.15
|
| Rate for Payer: Cigna of CA HMO |
$65.11
|
| Rate for Payer: Cigna of CA PPO |
$65.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.20
|
| Rate for Payer: EPIC Health Plan Senior |
$37.20
|
| Rate for Payer: Galaxy Health WC |
$79.06
|
| Rate for Payer: Global Benefits Group Commercial |
$55.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$62.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.32
|
| Rate for Payer: Multiplan Commercial |
$74.41
|
| Rate for Payer: Networks By Design Commercial |
$60.46
|
| Rate for Payer: Prime Health Services Commercial |
$79.06
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
OP
|
$93.01
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Adventist Health Commercial |
$18.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$61.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$79.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.12
|
| Rate for Payer: Cash Price |
$51.15
|
| Rate for Payer: Cigna of CA HMO |
$65.11
|
| Rate for Payer: Cigna of CA PPO |
$65.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$79.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$79.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$79.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.20
|
| Rate for Payer: EPIC Health Plan Senior |
$37.20
|
| Rate for Payer: Galaxy Health WC |
$79.06
|
| Rate for Payer: Global Benefits Group Commercial |
$55.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$62.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$65.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.11
|
| Rate for Payer: Multiplan Commercial |
$74.41
|
| Rate for Payer: Networks By Design Commercial |
$60.46
|
| Rate for Payer: Prime Health Services Commercial |
$79.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$55.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$55.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$46.51
|
| Rate for Payer: United Healthcare All Other HMO |
$46.51
|
| Rate for Payer: United Healthcare HMO Rider |
$46.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$46.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$79.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$79.06
|
| Rate for Payer: Vantage Medical Group Senior |
$79.06
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
OP
|
$42.26
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$35.92 |
| Rate for Payer: Adventist Health Commercial |
$8.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.80
|
| Rate for Payer: Blue Shield of California Commercial |
$4.77
|
| Rate for Payer: Blue Shield of California EPN |
$4.77
|
| Rate for Payer: Cash Price |
$23.24
|
| Rate for Payer: Cash Price |
$23.24
|
| Rate for Payer: Cigna of CA HMO |
$29.58
|
| Rate for Payer: Cigna of CA PPO |
$29.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: EPIC Health Plan Senior |
$4.14
|
| Rate for Payer: Galaxy Health WC |
$35.92
|
| Rate for Payer: Global Benefits Group Commercial |
$25.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.55
|
| Rate for Payer: Multiplan Commercial |
$33.81
|
| Rate for Payer: Networks By Design Commercial |
$21.13
|
| Rate for Payer: Prime Health Services Commercial |
$35.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.86
|
| Rate for Payer: United Healthcare All Other HMO |
$15.44
|
| Rate for Payer: United Healthcare HMO Rider |
$15.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.84
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.55
|
| Rate for Payer: Vantage Medical Group Senior |
$4.55
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
IP
|
$42.26
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$35.92 |
| Rate for Payer: Adventist Health Commercial |
$8.45
|
| Rate for Payer: Blue Shield of California Commercial |
$31.19
|
| Rate for Payer: Blue Shield of California EPN |
$20.54
|
| Rate for Payer: Cash Price |
$23.24
|
| Rate for Payer: Cigna of CA HMO |
$29.58
|
| Rate for Payer: Cigna of CA PPO |
$29.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.90
|
| Rate for Payer: EPIC Health Plan Senior |
$16.90
|
| Rate for Payer: Galaxy Health WC |
$35.92
|
| Rate for Payer: Global Benefits Group Commercial |
$25.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.14
|
| Rate for Payer: Multiplan Commercial |
$33.81
|
| Rate for Payer: Networks By Design Commercial |
$21.13
|
| Rate for Payer: Prime Health Services Commercial |
$35.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.86
|
| Rate for Payer: United Healthcare All Other HMO |
$15.44
|
| Rate for Payer: United Healthcare HMO Rider |
$15.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.84
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6478-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
