|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
OP
|
$5.00
|
|
|
Service Code
|
NDC 59762-0038-2
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: BCBS Transplant Transplant |
$3.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$2.25
|
| 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 Media |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.90
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.00
|
| 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
|
$0.91
|
|
|
Service Code
|
NDC 69452-132-17
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: BCBS Transplant Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
OP
|
$1.92
|
|
|
Service Code
|
NDC 59651-119-60
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.86
|
| 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 Media |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
| 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
|
$1.92
|
|
|
Service Code
|
NDC 59651-119-60
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.86
|
| 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: 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: 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
IP
|
$0.91
|
|
|
Service Code
|
NDC 69452-132-17
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
IP
|
$5.70
|
|
|
Service Code
|
NDC 0069-5810-61
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$2.57
|
| 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: 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: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.56
|
| Rate for Payer: Networks By Design Commercial |
$3.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.84
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
OP
|
$5.70
|
|
|
Service Code
|
NDC 0069-5810-61
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.40
|
| Rate for Payer: BCBS Transplant Transplant |
$3.42
|
| Rate for Payer: Blue Shield of California Commercial |
$4.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.33
|
| Rate for Payer: Cash Price |
$2.57
|
| 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 Media |
$4.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.84
|
| Rate for Payer: Global Benefits Group Commercial |
$3.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.28
|
| 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: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.56
|
| Rate for Payer: Networks By Design Commercial |
$3.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.84
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.42
|
| 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
|
$1.92
|
|
|
Service Code
|
NDC 47335-062-86
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.86
|
| 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 Media |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
| 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
|
$5.00
|
|
|
Service Code
|
NDC 59762-0038-2
|
| Hospital Charge Code |
1710915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Blue Shield of California Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.56
|
| Rate for Payer: Cash Price |
$2.25
|
| 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: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.90
|
| 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 500 MCG CAPSULE [26967]
|
Facility
OP
|
$1.92
|
|
|
Service Code
|
NDC 47335-063-86
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.86
|
| 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 Media |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
| 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 500 MCG CAPSULE [26967]
|
Facility
IP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-43
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.74
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna of CA HMO |
$9.22
|
| Rate for Payer: Cigna of CA PPO |
$9.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.27
|
| Rate for Payer: Galaxy Health WC |
$11.19
|
| Rate for Payer: Global Benefits Group Commercial |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$10.54
|
| Rate for Payer: Networks By Design Commercial |
$8.56
|
| Rate for Payer: Prime Health Services Commercial |
$11.19
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
OP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-43
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.85
|
| Rate for Payer: BCBS Transplant Transplant |
$7.90
|
| Rate for Payer: Blue Shield of California Commercial |
$9.71
|
| Rate for Payer: Blue Shield of California EPN |
$7.69
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna of CA HMO |
$9.22
|
| Rate for Payer: Cigna of CA PPO |
$9.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Media |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.27
|
| Rate for Payer: Galaxy Health WC |
$11.19
|
| Rate for Payer: Global Benefits Group Commercial |
$7.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$10.54
|
| Rate for Payer: Networks By Design Commercial |
$8.56
|
| Rate for Payer: Prime Health Services Commercial |
$11.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.58
|
| Rate for Payer: United Healthcare All Other HMO |
$6.58
|
| Rate for Payer: United Healthcare HMO Rider |
$6.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.19
|
| Rate for Payer: Vantage Medical Group Senior |
$11.19
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
OP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: Galaxy Health WC |
$11.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.85
|
| Rate for Payer: BCBS Transplant Transplant |
$7.90
|
| Rate for Payer: Blue Shield of California Commercial |
$9.71
|
| Rate for Payer: Blue Shield of California EPN |
$7.69
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna of CA HMO |
$9.22
|
| Rate for Payer: Cigna of CA PPO |
$9.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Media |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.27
|
| Rate for Payer: Global Benefits Group Commercial |
$7.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$10.54
|
| Rate for Payer: Networks By Design Commercial |
$8.56
|
| Rate for Payer: Prime Health Services Commercial |
$11.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.58
|
| Rate for Payer: United Healthcare All Other HMO |
$6.58
|
| Rate for Payer: United Healthcare HMO Rider |
$6.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.19
|
| Rate for Payer: Vantage Medical Group Senior |
$11.19
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
IP
|
$1.92
|
|
|
Service Code
|
NDC 47335-063-86
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.86
|
| 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: 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: 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 500 MCG CAPSULE [26967]
|
Facility
IP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.74
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna of CA HMO |
$9.22
|
| Rate for Payer: Cigna of CA PPO |
$9.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.27
|
| Rate for Payer: Galaxy Health WC |
$11.19
|
| Rate for Payer: Global Benefits Group Commercial |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$10.54
|
| Rate for Payer: Networks By Design Commercial |
$8.56
|
| Rate for Payer: Prime Health Services Commercial |
$11.19
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
IP
|
$132.61
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
ERX220407
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.83 |
| Max. Negotiated Rate |
$112.72 |
| Rate for Payer: Blue Shield of California Commercial |
$94.42
|
| Rate for Payer: Blue Shield of California EPN |
$67.90
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cigna of CA HMO |
$92.83
|
| Rate for Payer: Cigna of CA PPO |
$92.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.04
|
| Rate for Payer: Galaxy Health WC |
$112.72
|
| Rate for Payer: Global Benefits Group Commercial |
$79.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$88.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.83
|
| Rate for Payer: Multiplan Commercial |
$106.09
|
| Rate for Payer: Networks By Design Commercial |
$86.20
|
| Rate for Payer: Prime Health Services Commercial |
$112.72
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
OP
|
$132.61
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
ERX220407
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.83 |
| Max. Negotiated Rate |
$112.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$86.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$112.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$72.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$72.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.01
|
| Rate for Payer: BCBS Transplant Transplant |
$79.57
|
| Rate for Payer: Blue Shield of California Commercial |
$97.73
|
| Rate for Payer: Blue Shield of California EPN |
$77.44
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cigna of CA HMO |
$92.83
|
| Rate for Payer: Cigna of CA PPO |
$92.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$112.72
|
| Rate for Payer: Dignity Health Media |
$112.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$112.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$53.04
|
| Rate for Payer: Galaxy Health WC |
$112.72
|
| Rate for Payer: Global Benefits Group Commercial |
$79.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$99.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$88.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.83
|
| Rate for Payer: Multiplan Commercial |
$106.09
|
| Rate for Payer: Networks By Design Commercial |
$86.20
|
| Rate for Payer: Prime Health Services Commercial |
$112.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$79.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$79.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$79.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$66.30
|
| Rate for Payer: United Healthcare All Other HMO |
$66.30
|
| Rate for Payer: United Healthcare HMO Rider |
$66.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$66.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$112.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$112.72
|
| Rate for Payer: Vantage Medical Group Senior |
$112.72
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
IP
|
$85.23
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
ERX201546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Blue Shield of California Commercial |
$60.68
|
| Rate for Payer: Blue Shield of California EPN |
$43.64
|
| Rate for Payer: Cash Price |
$38.35
|
| Rate for Payer: Cigna of CA HMO |
$59.66
|
| Rate for Payer: Cigna of CA PPO |
$59.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.09
|
| Rate for Payer: Galaxy Health WC |
$72.45
|
| Rate for Payer: Global Benefits Group Commercial |
$51.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.46
|
| Rate for Payer: Multiplan Commercial |
$68.18
|
| Rate for Payer: Networks By Design Commercial |
$55.40
|
| Rate for Payer: Prime Health Services Commercial |
$72.45
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
OP
|
$85.23
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
ERX201546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$72.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$46.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.78
|
| Rate for Payer: BCBS Transplant Transplant |
$51.14
|
| Rate for Payer: Blue Shield of California Commercial |
$62.81
|
| Rate for Payer: Blue Shield of California EPN |
$49.77
|
| Rate for Payer: Cash Price |
$38.35
|
| Rate for Payer: Cigna of CA HMO |
$59.66
|
| Rate for Payer: Cigna of CA PPO |
$59.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.45
|
| Rate for Payer: Dignity Health Media |
$72.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$34.09
|
| Rate for Payer: Galaxy Health WC |
$72.45
|
| Rate for Payer: Global Benefits Group Commercial |
$51.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$63.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.46
|
| Rate for Payer: Multiplan Commercial |
$68.18
|
| Rate for Payer: Networks By Design Commercial |
$55.40
|
| Rate for Payer: Prime Health Services Commercial |
$72.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$51.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$51.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$51.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.62
|
| Rate for Payer: United Healthcare All Other HMO |
$42.62
|
| Rate for Payer: United Healthcare HMO Rider |
$42.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.45
|
| Rate for Payer: Vantage Medical Group Senior |
$72.45
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6478-61
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| 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: 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: 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
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 59746-330-30
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 43547-276-03
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6478-61
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.12
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-01
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| 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: 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: 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
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-01
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.12
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
