|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0254-3029-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 0254-3029-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: InnovAge PACE Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Riverside University Health System MISP |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 0254-3028-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: InnovAge PACE Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Riverside University Health System MISP |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 64764-080-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$6.68 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.36
|
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.96
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Central Health Plan Commercial |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: EPIC Health Plan Senior |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.68
|
| Rate for Payer: InnovAge PACE Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.19
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
| Rate for Payer: Riverside University Health System MISP |
$2.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.71
|
| Rate for Payer: United Healthcare All Other HMO |
$3.71
|
| Rate for Payer: United Healthcare HMO Rider |
$3.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.31
|
| Rate for Payer: Vantage Medical Group Senior |
$6.31
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 64764-080-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$6.68 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Central Health Plan Commercial |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: EPIC Health Plan Senior |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0254-3028-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 60687-747-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$3.95
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 60687-747-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$3.95
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 60687-747-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.04
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: InnovAge PACE Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
| Rate for Payer: Riverside University Health System MISP |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 60687-747-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.04
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: InnovAge PACE Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
| Rate for Payer: Riverside University Health System MISP |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 47335-578-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 47335-578-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: InnovAge PACE Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.35 |
| Max. Negotiated Rate |
$51.08 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Blue Shield of California Commercial |
$43.87
|
| Rate for Payer: Blue Shield of California EPN |
$28.60
|
| Rate for Payer: Cash Price |
$31.21
|
| Rate for Payer: Central Health Plan Commercial |
$45.40
|
| Rate for Payer: Cigna of CA HMO |
$39.73
|
| Rate for Payer: Cigna of CA PPO |
$39.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.70
|
| Rate for Payer: EPIC Health Plan Senior |
$22.70
|
| Rate for Payer: Galaxy Health WC |
$48.24
|
| Rate for Payer: Global Benefits Group Commercial |
$34.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$51.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.35
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
| Rate for Payer: Networks By Design Commercial |
$36.89
|
| Rate for Payer: Prime Health Services Commercial |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.97
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.35 |
| Max. Negotiated Rate |
$51.08 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$34.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$27.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.33
|
| Rate for Payer: Blue Shield of California Commercial |
$34.67
|
| Rate for Payer: Blue Shield of California EPN |
$22.64
|
| Rate for Payer: Cash Price |
$31.21
|
| Rate for Payer: Central Health Plan Commercial |
$45.40
|
| Rate for Payer: Cigna of CA HMO |
$39.73
|
| Rate for Payer: Cigna of CA PPO |
$39.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.70
|
| Rate for Payer: EPIC Health Plan Senior |
$22.70
|
| Rate for Payer: Galaxy Health WC |
$48.24
|
| Rate for Payer: Global Benefits Group Commercial |
$34.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$51.08
|
| Rate for Payer: InnovAge PACE Commercial |
$28.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.73
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
| Rate for Payer: Networks By Design Commercial |
$36.89
|
| Rate for Payer: Prime Health Services Commercial |
$48.24
|
| Rate for Payer: Riverside University Health System MISP |
$22.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$34.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$34.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.38
|
| Rate for Payer: United Healthcare All Other HMO |
$28.38
|
| Rate for Payer: United Healthcare HMO Rider |
$28.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.24
|
| Rate for Payer: Vantage Medical Group Senior |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.97
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: InnovAge PACE Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Riverside University Health System MISP |
$2.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: InnovAge PACE Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: InnovAge PACE Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Riverside University Health System MISP |
$2.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
IP
|
$518.20
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$466.38 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Blue Shield of California Commercial |
$400.57
|
| Rate for Payer: Blue Shield of California EPN |
$261.17
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: Central Health Plan Commercial |
$414.56
|
| Rate for Payer: Cigna of CA HMO |
$362.74
|
| Rate for Payer: Cigna of CA PPO |
$362.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.28
|
| Rate for Payer: EPIC Health Plan Senior |
$207.28
|
| Rate for Payer: Galaxy Health WC |
$440.47
|
| Rate for Payer: Global Benefits Group Commercial |
$310.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$466.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$345.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$197.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$320.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.64
|
| Rate for Payer: Multiplan Commercial |
$388.65
|
| Rate for Payer: Networks By Design Commercial |
$336.83
|
| Rate for Payer: Prime Health Services Commercial |
$440.47
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
OP
|
$518.20
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$466.38 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$314.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$440.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$285.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$388.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$250.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$304.34
|
| Rate for Payer: Blue Shield of California Commercial |
$316.62
|
| Rate for Payer: Blue Shield of California EPN |
$206.76
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: Central Health Plan Commercial |
$414.56
|
| Rate for Payer: Cigna of CA HMO |
$362.74
|
| Rate for Payer: Cigna of CA PPO |
$362.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$440.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$440.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$440.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.28
|
| Rate for Payer: EPIC Health Plan Senior |
$207.28
|
| Rate for Payer: Galaxy Health WC |
$440.47
|
| Rate for Payer: Global Benefits Group Commercial |
$310.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$466.38
|
| Rate for Payer: InnovAge PACE Commercial |
$259.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$345.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$197.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$320.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$362.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$362.74
|
| Rate for Payer: Multiplan Commercial |
$388.65
|
| Rate for Payer: Networks By Design Commercial |
$336.83
|
| Rate for Payer: Prime Health Services Commercial |
$440.47
|
| Rate for Payer: Riverside University Health System MISP |
$207.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$310.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$310.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$259.10
|
| Rate for Payer: United Healthcare All Other HMO |
$259.10
|
| Rate for Payer: United Healthcare HMO Rider |
$259.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$259.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$440.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$440.47
|
| Rate for Payer: Vantage Medical Group Senior |
$440.47
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
OP
|
$518.20
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$466.38 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$314.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$440.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$285.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$388.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$250.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$304.34
|
| Rate for Payer: Blue Shield of California Commercial |
$316.62
|
| Rate for Payer: Blue Shield of California EPN |
$206.76
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: Central Health Plan Commercial |
$414.56
|
| Rate for Payer: Cigna of CA HMO |
$362.74
|
| Rate for Payer: Cigna of CA PPO |
$362.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$440.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$440.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$440.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.28
|
| Rate for Payer: EPIC Health Plan Senior |
$207.28
|
| Rate for Payer: Galaxy Health WC |
$440.47
|
| Rate for Payer: Global Benefits Group Commercial |
$310.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$466.38
|
| Rate for Payer: InnovAge PACE Commercial |
$259.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$345.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$197.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$320.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$362.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$362.74
|
| Rate for Payer: Multiplan Commercial |
$388.65
|
| Rate for Payer: Networks By Design Commercial |
$336.83
|
| Rate for Payer: Prime Health Services Commercial |
$440.47
|
| Rate for Payer: Riverside University Health System MISP |
$207.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$310.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$310.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$259.10
|
| Rate for Payer: United Healthcare All Other HMO |
$259.10
|
| Rate for Payer: United Healthcare HMO Rider |
$259.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$259.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$440.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$440.47
|
| Rate for Payer: Vantage Medical Group Senior |
$440.47
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
IP
|
$518.20
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$466.38 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Blue Shield of California Commercial |
$400.57
|
| Rate for Payer: Blue Shield of California EPN |
$261.17
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: Central Health Plan Commercial |
$414.56
|
| Rate for Payer: Cigna of CA HMO |
$362.74
|
| Rate for Payer: Cigna of CA PPO |
$362.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.28
|
| Rate for Payer: EPIC Health Plan Senior |
$207.28
|
| Rate for Payer: Galaxy Health WC |
$440.47
|
| Rate for Payer: Global Benefits Group Commercial |
$310.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$466.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$345.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$197.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$320.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.64
|
| Rate for Payer: Multiplan Commercial |
$388.65
|
| Rate for Payer: Networks By Design Commercial |
$336.83
|
| Rate for Payer: Prime Health Services Commercial |
$440.47
|
|
|
Macular Degeneration
|
Facility
|
OP
|
$3,000.00
|
|
|
Hospital Revenue Code
|
339
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,000.00
|
|
