|
DOFETILIDE 250 MCG CAPSULE [26966]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 7220504060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| 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 Foundation Hospitals 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
|
IP
|
$13.43
|
|
|
Service Code
|
NDC 0069582061
|
| 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: Aetna of CA Non-Gatekeeper |
$8.65
|
| Rate for Payer: Cash Price |
$6.04
|
| 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 Foundation Hospitals 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 0069582061
|
| 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 Non-Gatekeeper |
$8.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.72
|
| 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 |
$6.04
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$6.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0904668308
|
| 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: Aetna of CA Non-Gatekeeper |
$4.07
|
| Rate for Payer: Cash Price |
$2.84
|
| 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 Foundation Hospitals 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
|
$0.40
|
|
|
Service Code
|
NDC 7220504160
|
| 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 Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| 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 |
$0.18
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$6.32
|
|
|
Service Code
|
NDC 0904668308
|
| 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 Non-Gatekeeper |
$3.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.16
|
| 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 |
$2.84
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$3.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 7220504160
|
| 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: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| 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 Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
OP
|
$150.49
|
|
|
Service Code
|
NDC 4970224213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.24 |
| Max. Negotiated Rate |
$127.92 |
| Rate for Payer: Adventist Health Commercial |
$30.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$127.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$112.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.28
|
| Rate for Payer: Blue Shield of California Commercial |
$91.80
|
| Rate for Payer: Blue Shield of California EPN |
$73.44
|
| Rate for Payer: Cash Price |
$67.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$127.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$127.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$93.15
|
| Rate for Payer: Heritage Provider Network Senior |
$93.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$71.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$105.34
|
| Rate for Payer: Multiplan Commercial |
$112.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$60.20
|
| Rate for Payer: TriValley Medical Group Senior |
$60.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$127.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$127.92
|
| Rate for Payer: Vantage Medical Group Senior |
$127.92
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]
|
Facility
|
IP
|
$150.49
|
|
|
Service Code
|
NDC 4970224213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.24 |
| Max. Negotiated Rate |
$112.87 |
| Rate for Payer: Adventist Health Commercial |
$30.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.92
|
| Rate for Payer: Cash Price |
$67.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.88
|
| Rate for Payer: Heritage Provider Network Senior |
$101.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.62
|
| Rate for Payer: Multiplan Commercial |
$112.87
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
IP
|
$95.80
|
|
|
Service Code
|
NDC 4970222813
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$71.85 |
| Rate for Payer: Adventist Health Commercial |
$19.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.70
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.86
|
| Rate for Payer: Heritage Provider Network Senior |
$64.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.95
|
| Rate for Payer: Multiplan Commercial |
$71.85
|
|
|
DOLUTEGRAVIR 50 MG TABLET [201546]
|
Facility
|
OP
|
$95.80
|
|
|
Service Code
|
NDC 4970222813
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$81.43 |
| Rate for Payer: Adventist Health Commercial |
$19.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$59.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.92
|
| Rate for Payer: Blue Shield of California Commercial |
$58.44
|
| Rate for Payer: Blue Shield of California EPN |
$46.75
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$81.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.30
|
| Rate for Payer: Heritage Provider Network Senior |
$59.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.06
|
| Rate for Payer: Multiplan Commercial |
$71.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.32
|
| Rate for Payer: TriValley Medical Group Senior |
$38.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$47.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.43
|
| Rate for Payer: Vantage Medical Group Senior |
$81.43
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
OP
|
$43.07
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Adventist Health Commercial |
$8.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.58
|
| 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 |
$19.38
|
| Rate for Payer: Cash Price |
$19.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.94
|
| Rate for Payer: Heritage Provider Network Senior |
$19.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$20.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.59
|
| Rate for Payer: Multiplan Commercial |
$32.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.23
|
| Rate for Payer: TriValley Medical Group Senior |
$17.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]
|
Facility
|
IP
|
$43.07
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Adventist Health Commercial |
$8.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.74
|
| Rate for Payer: Cash Price |
$19.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.94
|
| Rate for Payer: Heritage Provider Network Senior |
$19.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.77
|
| Rate for Payer: Multiplan Commercial |
$32.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.26
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904647861
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| 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 |
$0.07
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 6068730311
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| 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 |
$0.07
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.14
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 6068730301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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 Foundation Hospitals 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 6068730301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| 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 |
$0.07
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0904647861
|
| 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: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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 Foundation Hospitals 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 6068730311
|
| 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: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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 Foundation Hospitals 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
|
$0.12
|
|
|
Service Code
|
NDC 4354727603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
DONEPEZIL 10 MG TABLET [18787]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 4354727603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904647761
|
| 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: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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 Foundation Hospitals 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
|
$0.18
|
|
|
Service Code
|
NDC 1366810230
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$0.11
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| 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: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| 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
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 5976202453
|
| 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 Non-Gatekeeper |
$0.32
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| 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 |
$0.23
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.52
|
|
|
Service Code
|
NDC 5976202453
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
