|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 69452-132-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 69452-132-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| 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: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$13.43
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.07 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.09
|
| Rate for Payer: Heritage Provider Network Senior |
$9.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$10.07
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$13.43
|
|
|
Service Code
|
NDC 0069-5820-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$11.42 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.23
|
| 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: Blue Shield of California Commercial |
$8.19
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.42
|
| Rate for Payer: Dignity Health Senior |
$11.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.31
|
| Rate for Payer: Heritage Provider Network Senior |
$8.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.40
|
| Rate for Payer: Multiplan Commercial |
$10.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.37
|
| Rate for Payer: TriValley Medical Group Senior |
$5.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$6.32
|
|
|
Service Code
|
NDC 0904-6683-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.28
|
| Rate for Payer: Heritage Provider Network Senior |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.74
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$6.32
|
|
|
Service Code
|
NDC 0904-6683-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.37 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.34
|
| 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: Blue Shield of California Commercial |
$3.86
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.37
|
| Rate for Payer: Dignity Health Senior |
$5.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.91
|
| Rate for Payer: Heritage Provider Network Senior |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$4.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.53
|
| Rate for Payer: TriValley Medical Group Senior |
$2.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.40
|
|
|
Service Code
|
NDC 72205-041-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
DOFETILIDE 500 MCG CAPSULE [26967]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 72205-041-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| 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: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
OP
|
$146.11
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.45 |
| Max. Negotiated Rate |
$124.19 |
| Rate for Payer: Adventist Health Commercial |
$29.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$78.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$124.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$109.58
|
| Rate for Payer: Blue Shield of California Commercial |
$89.13
|
| Rate for Payer: Blue Shield of California EPN |
$71.30
|
| Rate for Payer: Cash Price |
$80.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$124.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.19
|
| Rate for Payer: Dignity Health Senior |
$124.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.44
|
| Rate for Payer: Heritage Provider Network Senior |
$90.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$69.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$102.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$102.28
|
| Rate for Payer: Multiplan Commercial |
$109.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$58.44
|
| Rate for Payer: TriValley Medical Group Senior |
$58.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$73.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$73.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$124.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.19
|
| Rate for Payer: Vantage Medical Group Senior |
$124.19
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
IP
|
$146.11
|
|
|
Service Code
|
NDC 49702-242-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.45 |
| Max. Negotiated Rate |
$109.58 |
| Rate for Payer: Adventist Health Commercial |
$29.22
|
| Rate for Payer: Cash Price |
$80.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.92
|
| Rate for Payer: Heritage Provider Network Senior |
$98.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.53
|
| Rate for Payer: Multiplan Commercial |
$109.58
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
OP
|
$93.01
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Adventist Health Commercial |
$18.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$63.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$79.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.76
|
| Rate for Payer: Blue Shield of California Commercial |
$56.74
|
| Rate for Payer: Blue Shield of California EPN |
$45.39
|
| Rate for Payer: Cash Price |
$51.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$79.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$79.06
|
| Rate for Payer: Dignity Health Senior |
$79.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.57
|
| Rate for Payer: Heritage Provider Network Senior |
$57.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$44.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$65.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.11
|
| Rate for Payer: Multiplan Commercial |
$69.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.20
|
| Rate for Payer: TriValley Medical Group Senior |
$37.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$79.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$79.06
|
| Rate for Payer: Vantage Medical Group Senior |
$79.06
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
IP
|
$93.01
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$69.76 |
| Rate for Payer: Adventist Health Commercial |
$18.60
|
| Rate for Payer: Cash Price |
$51.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.97
|
| Rate for Payer: Heritage Provider Network Senior |
$62.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.25
|
| Rate for Payer: Multiplan Commercial |
$69.76
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
IP
|
$42.26
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$31.70 |
| Rate for Payer: Adventist Health Commercial |
$8.45
|
| Rate for Payer: Cash Price |
$23.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.57
|
| Rate for Payer: Heritage Provider Network Senior |
$19.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.56
|
| Rate for Payer: Multiplan Commercial |
$31.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.99
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
OP
|
$42.26
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$31.70 |
| Rate for Payer: Adventist Health Commercial |
$8.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.30
|
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California EPN |
$4.05
|
| Rate for Payer: Cash Price |
$23.24
|
| Rate for Payer: Cash Price |
$23.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.56
|
| Rate for Payer: Dignity Health Senior |
$4.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.57
|
| Rate for Payer: Heritage Provider Network Senior |
$19.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.22
|
| Rate for Payer: Multiplan Commercial |
$31.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.90
|
| Rate for Payer: TriValley Medical Group Senior |
$16.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.56
|
| Rate for Payer: Vantage Medical Group Senior |
$4.56
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 43547-276-03
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| 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: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-11
|
| 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 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 |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| 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: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-11
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.09
|
| 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
|
$0.16
|
|
|
Service Code
|
NDC 0904-6478-61
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.09
|
| 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 0904-6478-61
|
| 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 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 |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| 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: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.20
|
|
|
Service Code
|
NDC 43547-276-03
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.11
|
| 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
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-01
|
| 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 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 |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| 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: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 60687-303-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.09
|
| 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
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 59762-0245-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: Dignity Health Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 13668-102-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| 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
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6477-61
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.09
|
| 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
|
|
