|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-43
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Adventist Health Commercial |
$2.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.05
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.92
|
| Rate for Payer: Heritage Provider Network Senior |
$8.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$9.88
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-43
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: Adventist Health Commercial |
$2.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.88
|
| Rate for Payer: Blue Shield of California Commercial |
$8.18
|
| Rate for Payer: Blue Shield of California EPN |
$7.73
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.19
|
| Rate for Payer: Dignity Health Senior |
$11.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.15
|
| Rate for Payer: Heritage Provider Network Senior |
$8.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$9.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.27
|
| Rate for Payer: TriValley Medical Group Senior |
$5.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.19
|
| Rate for Payer: Vantage Medical Group Senior |
$11.19
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: Adventist Health Commercial |
$2.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.88
|
| Rate for Payer: Blue Shield of California Commercial |
$8.18
|
| Rate for Payer: Blue Shield of California EPN |
$7.73
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.19
|
| Rate for Payer: Dignity Health Senior |
$11.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.15
|
| Rate for Payer: Heritage Provider Network Senior |
$8.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$9.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.27
|
| Rate for Payer: TriValley Medical Group Senior |
$5.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.19
|
| Rate for Payer: Vantage Medical Group Senior |
$11.19
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$13.17
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Adventist Health Commercial |
$2.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.05
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.92
|
| Rate for Payer: Heritage Provider Network Senior |
$8.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$9.88
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 47335-063-86
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 47335-063-86
|
| Hospital Charge Code |
1710916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
OP
|
$132.61
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
ERX220407
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$112.72 |
| Rate for Payer: Adventist Health Commercial |
$26.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$70.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$112.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$72.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$99.46
|
| Rate for Payer: Blue Shield of California Commercial |
$82.35
|
| Rate for Payer: Blue Shield of California EPN |
$77.84
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$86.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$112.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$112.72
|
| Rate for Payer: Dignity Health Senior |
$112.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.09
|
| Rate for Payer: Heritage Provider Network Senior |
$82.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$63.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.15
|
| Rate for Payer: Multiplan Commercial |
$99.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$53.04
|
| Rate for Payer: TriValley Medical Group Senior |
$53.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$112.72
|
| Rate for Payer: Vantage Medical Group Senior |
$112.72
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
IP
|
$132.61
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
ERX220407
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$99.46 |
| Rate for Payer: Adventist Health Commercial |
$26.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.10
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.78
|
| Rate for Payer: Heritage Provider Network Senior |
$89.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.15
|
| Rate for Payer: Multiplan Commercial |
$99.46
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
OP
|
$85.23
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
ERX201546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Adventist Health Commercial |
$17.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.92
|
| Rate for Payer: Blue Shield of California Commercial |
$52.93
|
| Rate for Payer: Blue Shield of California EPN |
$50.03
|
| Rate for Payer: Cash Price |
$38.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.45
|
| Rate for Payer: Dignity Health Senior |
$72.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.76
|
| Rate for Payer: Heritage Provider Network Senior |
$52.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.31
|
| Rate for Payer: Multiplan Commercial |
$63.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$34.09
|
| Rate for Payer: TriValley Medical Group Senior |
$34.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.45
|
| Rate for Payer: Vantage Medical Group Senior |
$72.45
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
IP
|
$85.23
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
ERX201546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$63.92 |
| Rate for Payer: Adventist Health Commercial |
$17.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.55
|
| Rate for Payer: Cash Price |
$38.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.70
|
| Rate for Payer: Heritage Provider Network Senior |
$57.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.31
|
| Rate for Payer: Multiplan Commercial |
$63.92
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 43547-276-03
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-11
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-01
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| 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: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| 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
|
$0.20
|
|
|
Service Code
|
NDC 43547-276-03
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6478-61
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 59746-330-30
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 59746-330-30
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6478-61
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| 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: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| 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 60687-303-11
|
| Hospital Charge Code |
1711716
|
|
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 Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| 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: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-01
|
| Hospital Charge Code |
1711716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 13668-102-30
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-102-30
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 59762-0245-3
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6477-61
|
| Hospital Charge Code |
1711717
|
|
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 Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| 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: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| 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
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 43547-275-03
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
