|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$4.83
|
|
|
Service Code
|
NDC 0904752308
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$3.87
|
| Rate for Payer: Blue Shield of California EPN |
$2.43
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Central Health Plan Commercial |
$3.86
|
| Rate for Payer: Cigna of CA HMO |
$3.38
|
| Rate for Payer: Cigna of CA PPO |
$3.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.93
|
| Rate for Payer: EPIC Health Plan Senior |
$1.93
|
| Rate for Payer: Galaxy Health WC |
$4.11
|
| Rate for Payer: Global Benefits Group Commercial |
$2.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$3.62
|
| Rate for Payer: Networks By Design Commercial |
$3.14
|
| Rate for Payer: Prime Health Services Commercial |
$4.11
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 7220504060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| 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
|
$4.83
|
|
|
Service Code
|
NDC 0904752308
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.81
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Central Health Plan Commercial |
$3.86
|
| Rate for Payer: Cigna of CA HMO |
$3.38
|
| Rate for Payer: Cigna of CA PPO |
$3.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.93
|
| Rate for Payer: EPIC Health Plan Senior |
$1.93
|
| Rate for Payer: Galaxy Health WC |
$4.11
|
| Rate for Payer: Global Benefits Group Commercial |
$2.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$3.62
|
| Rate for Payer: Networks By Design Commercial |
$3.14
|
| Rate for Payer: Prime Health Services Commercial |
$4.11
|
| Rate for Payer: Riverside University Health System MISP |
$1.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.42
|
| Rate for Payer: United Healthcare All Other HMO |
$2.42
|
| Rate for Payer: United Healthcare HMO Rider |
$2.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Vantage Medical Group Senior |
$4.11
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 7220504060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| 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 Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| 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
|
OP
|
$6.32
|
|
|
Service Code
|
NDC 0904668308
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.84
|
| 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 Exchange |
$3.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.68
|
| Rate for Payer: Blue Shield of California Commercial |
$4.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.06
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$5.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$4.74
|
| Rate for Payer: Networks By Design Commercial |
$4.11
|
| Rate for Payer: Prime Health Services Commercial |
$5.37
|
| Rate for Payer: Riverside University Health System MISP |
$2.53
|
| 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
|
$13.43
|
|
|
Service Code
|
NDC 0069582061
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$12.09 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California Commercial |
$10.77
|
| Rate for Payer: Blue Shield of California EPN |
$6.77
|
| Rate for Payer: Cash Price |
$6.04
|
| Rate for Payer: Central Health Plan Commercial |
$10.74
|
| Rate for Payer: Cigna of CA HMO |
$9.40
|
| Rate for Payer: Cigna of CA PPO |
$9.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$12.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$10.07
|
| Rate for Payer: Networks By Design Commercial |
$8.73
|
| Rate for Payer: Prime Health Services Commercial |
$11.42
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 7220504160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| 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 0069582061
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$12.09 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.16
|
| 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 Exchange |
$6.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.81
|
| Rate for Payer: Blue Shield of California Commercial |
$8.51
|
| Rate for Payer: Blue Shield of California EPN |
$5.36
|
| Rate for Payer: Cash Price |
$6.04
|
| Rate for Payer: Central Health Plan Commercial |
$10.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$12.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.40
|
| Rate for Payer: Multiplan Commercial |
$10.07
|
| Rate for Payer: Networks By Design Commercial |
$8.73
|
| Rate for Payer: Prime Health Services Commercial |
$11.42
|
| Rate for Payer: Riverside University Health System MISP |
$5.37
|
| 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
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 7220504160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| 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 Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| 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
|
$6.32
|
|
|
Service Code
|
NDC 0904668308
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$5.07
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.06
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$5.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$4.74
|
| 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
|
$150.49
|
|
|
Service Code
|
NDC 4970224213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$135.44 |
| Rate for Payer: Adventist Health Commercial |
$30.10
|
| Rate for Payer: Blue Shield of California Commercial |
$120.69
|
| Rate for Payer: Blue Shield of California EPN |
$75.85
|
| Rate for Payer: Cash Price |
$67.72
|
| Rate for Payer: Central Health Plan Commercial |
$120.39
|
| Rate for Payer: Cigna of CA HMO |
$105.34
|
| Rate for Payer: Cigna of CA PPO |
$105.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$105.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.20
|
| Rate for Payer: EPIC Health Plan Senior |
$60.20
|
| Rate for Payer: Galaxy Health WC |
$127.92
|
| Rate for Payer: Global Benefits Group Commercial |
$90.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$135.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$95.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$88.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.10
|
| Rate for Payer: Multiplan Commercial |
$112.87
|
| Rate for Payer: Networks By Design Commercial |
$97.82
|
| Rate for Payer: Prime Health Services Commercial |
$127.92
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
OP
|
$150.49
|
|
|
Service Code
|
NDC 4970224213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$135.44 |
| Rate for Payer: Adventist Health Commercial |
$30.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$91.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$127.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$112.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$72.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.54
|
| Rate for Payer: Blue Shield of California Commercial |
$95.41
|
| Rate for Payer: Blue Shield of California EPN |
$60.05
|
| Rate for Payer: Cash Price |
$67.72
|
| Rate for Payer: Central Health Plan Commercial |
$120.39
|
| Rate for Payer: Cigna of CA HMO |
$105.34
|
| Rate for Payer: Cigna of CA PPO |
$105.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$127.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$127.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$105.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.20
|
| Rate for Payer: EPIC Health Plan Senior |
$60.20
|
| Rate for Payer: Galaxy Health WC |
$127.92
|
| Rate for Payer: Global Benefits Group Commercial |
$90.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$135.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$95.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$54.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$88.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$105.34
|
| Rate for Payer: Multiplan Commercial |
$112.87
|
| Rate for Payer: Networks By Design Commercial |
$97.82
|
| Rate for Payer: Prime Health Services Commercial |
$127.92
|
| Rate for Payer: Riverside University Health System MISP |
$60.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.25
|
| Rate for Payer: United Healthcare All Other HMO |
$75.25
|
| Rate for Payer: United Healthcare HMO Rider |
$75.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$127.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$127.92
|
| Rate for Payer: Vantage Medical Group Senior |
$127.92
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
OP
|
$95.80
|
|
|
Service Code
|
NDC 4970222813
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.16 |
| Max. Negotiated Rate |
$86.22 |
| Rate for Payer: Adventist Health Commercial |
$19.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$58.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$46.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.73
|
| Rate for Payer: Blue Shield of California Commercial |
$60.74
|
| Rate for Payer: Blue Shield of California EPN |
$38.22
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Central Health Plan Commercial |
$76.64
|
| Rate for Payer: Cigna of CA HMO |
$67.06
|
| Rate for Payer: Cigna of CA PPO |
$67.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$81.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.32
|
| Rate for Payer: EPIC Health Plan Senior |
$38.32
|
| Rate for Payer: Galaxy Health WC |
$81.43
|
| Rate for Payer: Global Benefits Group Commercial |
$57.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$34.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.06
|
| Rate for Payer: Multiplan Commercial |
$71.85
|
| Rate for Payer: Networks By Design Commercial |
$62.27
|
| Rate for Payer: Prime Health Services Commercial |
$81.43
|
| Rate for Payer: Riverside University Health System MISP |
$38.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.90
|
| Rate for Payer: United Healthcare All Other HMO |
$47.90
|
| Rate for Payer: United Healthcare HMO Rider |
$47.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.43
|
| Rate for Payer: Vantage Medical Group Senior |
$81.43
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
IP
|
$95.80
|
|
|
Service Code
|
NDC 4970222813
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.16 |
| Max. Negotiated Rate |
$86.22 |
| Rate for Payer: Adventist Health Commercial |
$19.16
|
| Rate for Payer: Blue Shield of California Commercial |
$76.83
|
| Rate for Payer: Blue Shield of California EPN |
$48.28
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Central Health Plan Commercial |
$76.64
|
| Rate for Payer: Cigna of CA HMO |
$67.06
|
| Rate for Payer: Cigna of CA PPO |
$67.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.32
|
| Rate for Payer: EPIC Health Plan Senior |
$38.32
|
| Rate for Payer: Galaxy Health WC |
$81.43
|
| Rate for Payer: Global Benefits Group Commercial |
$57.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$71.85
|
| Rate for Payer: Networks By Design Commercial |
$62.27
|
| Rate for Payer: Prime Health Services Commercial |
$81.43
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
IP
|
$43.07
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.61 |
| Max. Negotiated Rate |
$38.76 |
| Rate for Payer: Adventist Health Commercial |
$8.61
|
| Rate for Payer: Blue Shield of California Commercial |
$34.54
|
| Rate for Payer: Blue Shield of California EPN |
$21.71
|
| Rate for Payer: Cash Price |
$19.38
|
| Rate for Payer: Central Health Plan Commercial |
$34.46
|
| Rate for Payer: Cigna of CA HMO |
$30.15
|
| Rate for Payer: Cigna of CA PPO |
$30.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$30.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.23
|
| Rate for Payer: EPIC Health Plan Senior |
$17.23
|
| Rate for Payer: Galaxy Health WC |
$36.61
|
| Rate for Payer: Global Benefits Group Commercial |
$25.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$38.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$32.30
|
| Rate for Payer: Networks By Design Commercial |
$21.54
|
| Rate for Payer: Prime Health Services Commercial |
$36.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.16
|
| Rate for Payer: United Healthcare All Other HMO |
$15.73
|
| Rate for Payer: United Healthcare HMO Rider |
$15.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.11
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
OP
|
$43.07
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$38.76 |
| Rate for Payer: Adventist Health Commercial |
$8.61
|
| Rate for Payer: Adventist Health Medi-Cal |
$4.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$25.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.76
|
| Rate for Payer: Blue Shield of California Commercial |
$5.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.77
|
| Rate for Payer: Cash Price |
$19.38
|
| Rate for Payer: Cash Price |
$19.38
|
| Rate for Payer: Central Health Plan Commercial |
$34.46
|
| Rate for Payer: Cigna of CA HMO |
$30.15
|
| Rate for Payer: Cigna of CA PPO |
$30.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$30.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.88
|
| Rate for Payer: EPIC Health Plan Senior |
$4.59
|
| Rate for Payer: Galaxy Health WC |
$36.61
|
| Rate for Payer: Global Benefits Group Commercial |
$25.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$38.76
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.59
|
| Rate for Payer: Multiplan Commercial |
$32.30
|
| Rate for Payer: Networks By Design Commercial |
$21.54
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4.17
|
| Rate for Payer: Prime Health Services Commercial |
$36.61
|
| Rate for Payer: Prime Health Services Medicare |
$4.42
|
| Rate for Payer: Riverside University Health System MISP |
$4.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.16
|
| Rate for Payer: United Healthcare All Other HMO |
$15.73
|
| Rate for Payer: United Healthcare HMO Rider |
$15.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.11
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904647861
|
| 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 |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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 0904647861
|
| 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: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| 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
|
$0.12
|
|
|
Service Code
|
NDC 4354727603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 6068730301
|
| 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 |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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
|
$0.12
|
|
|
Service Code
|
NDC 4354727603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Riverside University Health System MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 6068730311
|
| 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 |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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 6068730311
|
| 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: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| 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
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 6068730301
|
| 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: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| 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 5 MG TABLET [18786]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 5976202453
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
|
