|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 0480-4138-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| 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: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| 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: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 0480-4138-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
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 |
$1.34 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.10
|
| 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: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.62
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.31
|
| Rate for Payer: Dignity Health Senior |
$6.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.59
|
| Rate for Payer: Heritage Provider Network Senior |
$4.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| 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: TriValley Medical Group Commercial |
$2.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$1.34 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.02
|
| Rate for Payer: Heritage Provider Network Senior |
$5.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| 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: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| 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: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
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 |
$0.92 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
|
|
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 |
$0.92 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.51
|
| 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: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Senior |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| 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: TriValley Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Senior |
$2.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.80
|
|
|
Service Code
|
NDC 47335-578-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| 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: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| 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: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$0.92 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
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 |
$0.92 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.51
|
| 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: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Senior |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| 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: TriValley Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Senior |
$2.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
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 |
$10.27 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.99
|
| 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: Blue Shield of California Commercial |
$34.62
|
| Rate for Payer: Blue Shield of California EPN |
$27.69
|
| Rate for Payer: Cash Price |
$31.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.24
|
| Rate for Payer: Dignity Health Senior |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.13
|
| Rate for Payer: Heritage Provider Network Senior |
$35.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.19
|
| 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: TriValley Medical Group Commercial |
$22.70
|
| Rate for Payer: TriValley Medical Group Senior |
$22.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.93 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
|
|
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 |
$0.93 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
|
|
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 |
$0.93 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| 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: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.50
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Senior |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Senior |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| 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: TriValley Medical Group Commercial |
$2.05
|
| Rate for Payer: TriValley Medical Group Senior |
$2.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| 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: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.50
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Senior |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Senior |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| 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: TriValley Medical Group Commercial |
$2.05
|
| Rate for Payer: TriValley Medical Group Senior |
$2.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| 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: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| 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: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$42.56 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Cash Price |
$31.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.42
|
| Rate for Payer: Heritage Provider Network Senior |
$38.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.19
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
|
|
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 |
$93.79 |
| Max. Negotiated Rate |
$440.47 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$276.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$356.00
|
| 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: Blue Shield of California Commercial |
$316.10
|
| Rate for Payer: Blue Shield of California EPN |
$252.88
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$336.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$440.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$440.47
|
| Rate for Payer: Dignity Health Senior |
$440.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$331.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$320.77
|
| Rate for Payer: Heritage Provider Network Senior |
$320.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$247.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.55
|
| 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: TriValley Medical Group Commercial |
$207.28
|
| Rate for Payer: TriValley Medical Group Senior |
$207.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$259.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$93.79 |
| Max. Negotiated Rate |
$388.65 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$279.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$350.82
|
| Rate for Payer: Heritage Provider Network Senior |
$350.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.55
|
| Rate for Payer: Multiplan Commercial |
$388.65
|
|
|
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 |
$93.79 |
| Max. Negotiated Rate |
$388.65 |
| Rate for Payer: Adventist Health Commercial |
$103.64
|
| Rate for Payer: Cash Price |
$285.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$279.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$350.82
|
| Rate for Payer: Heritage Provider Network Senior |
$350.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.55
|
| Rate for Payer: Multiplan Commercial |
$388.65
|
|
