|
ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION [214353]
|
Facility
|
IP
|
$620.83
|
|
|
Service Code
|
CPT J9022
|
| Hospital Charge Code |
NDG214353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.37 |
| Max. Negotiated Rate |
$465.62 |
| Rate for Payer: Adventist Health Commercial |
$124.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$426.51
|
| Rate for Payer: Cash Price |
$279.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$285.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$335.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$420.30
|
| Rate for Payer: Heritage Provider Network Senior |
$420.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.21
|
| Rate for Payer: Multiplan Commercial |
$465.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$226.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$207.42
|
|
|
ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION [214353]
|
Facility
|
OP
|
$620.83
|
|
|
Service Code
|
CPT J9022
|
| Hospital Charge Code |
NDG214353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.72 |
| Max. Negotiated Rate |
$465.62 |
| Rate for Payer: Adventist Health Commercial |
$124.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$167.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$426.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$106.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$93.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$93.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.48
|
| Rate for Payer: Blue Shield of California Commercial |
$83.72
|
| Rate for Payer: Blue Shield of California EPN |
$83.72
|
| Rate for Payer: Cash Price |
$279.37
|
| Rate for Payer: Cash Price |
$279.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$285.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.51
|
| Rate for Payer: Dignity Health Senior |
$93.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$397.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$85.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$287.44
|
| Rate for Payer: Heritage Provider Network Senior |
$287.44
|
| Rate for Payer: Humana Medicare |
$85.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$139.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$85.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$161.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$100.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$107.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$107.11
|
| Rate for Payer: Multiplan Commercial |
$465.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$248.33
|
| Rate for Payer: TriValley Medical Group Senior |
$248.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$226.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$207.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$127.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.51
|
| Rate for Payer: Vantage Medical Group Senior |
$85.01
|
|
|
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION [224360]
|
Facility
|
OP
|
$620.83
|
|
|
Service Code
|
CPT J9022
|
| Hospital Charge Code |
NDG224360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.72 |
| Max. Negotiated Rate |
$465.62 |
| Rate for Payer: Adventist Health Commercial |
$124.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$167.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$426.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$106.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$93.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$93.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.48
|
| Rate for Payer: Blue Shield of California Commercial |
$83.72
|
| Rate for Payer: Blue Shield of California EPN |
$83.72
|
| Rate for Payer: Cash Price |
$279.37
|
| Rate for Payer: Cash Price |
$279.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$285.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.51
|
| Rate for Payer: Dignity Health Senior |
$93.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$397.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$85.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$287.44
|
| Rate for Payer: Heritage Provider Network Senior |
$287.44
|
| Rate for Payer: Humana Medicare |
$85.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$139.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$85.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$161.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$100.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$107.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$107.11
|
| Rate for Payer: Multiplan Commercial |
$465.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$248.33
|
| Rate for Payer: TriValley Medical Group Senior |
$248.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$226.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$207.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$127.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.51
|
| Rate for Payer: Vantage Medical Group Senior |
$85.01
|
|
|
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION [224360]
|
Facility
|
IP
|
$620.83
|
|
|
Service Code
|
CPT J9022
|
| Hospital Charge Code |
NDG224360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.37 |
| Max. Negotiated Rate |
$465.62 |
| Rate for Payer: Adventist Health Commercial |
$124.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$426.51
|
| Rate for Payer: Cash Price |
$279.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$285.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$335.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$420.30
|
| Rate for Payer: Heritage Provider Network Senior |
$420.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.21
|
| Rate for Payer: Multiplan Commercial |
$465.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$226.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$207.42
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$15.82
|
|
|
Service Code
|
NDC 0002-3227-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.87
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.71
|
| Rate for Payer: Heritage Provider Network Senior |
$10.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.86
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 55111-519-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
OP
|
$15.82
|
|
|
Service Code
|
NDC 0002-3227-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.86
|
| Rate for Payer: Blue Shield of California Commercial |
$9.82
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.45
|
| Rate for Payer: Dignity Health Senior |
$13.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.79
|
| Rate for Payer: Heritage Provider Network Senior |
$9.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.33
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.45
|
| Rate for Payer: Vantage Medical Group Senior |
$13.45
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 55111-519-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Senior |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Senior |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 64980-373-03
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Senior |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Senior |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 0093-3542-56
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Adventist Health Commercial |
$0.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.33
|
| Rate for Payer: Blue Shield of California Commercial |
$2.76
|
| Rate for Payer: Blue Shield of California EPN |
$2.61
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.77
|
| Rate for Payer: Dignity Health Senior |
$3.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Senior |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Senior |
$1.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.77
|
| Rate for Payer: Vantage Medical Group Senior |
$3.77
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
OP
|
$2.20
|
|
|
Service Code
|
NDC 31722-714-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.87
|
| Rate for Payer: Dignity Health Senior |
$1.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Senior |
$0.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.87
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
OP
|
$1.90
|
|
|
Service Code
|
NDC 68462-265-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.62
|
| Rate for Payer: Dignity Health Senior |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Senior |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Senior |
$0.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.62
|
| Rate for Payer: Vantage Medical Group Senior |
$1.62
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 64980-373-03
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$1.90
|
|
|
Service Code
|
NDC 68462-265-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$2.20
|
|
|
Service Code
|
NDC 31722-714-30
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.51
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Senior |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.65
|
|
|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 0093-3542-56
|
| Hospital Charge Code |
1711821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Adventist Health Commercial |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.05
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.01
|
| Rate for Payer: Heritage Provider Network Senior |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
|
|
ATOMOXETINE 18 MG CAPSULE [34445]
|
Facility
|
IP
|
$15.82
|
|
|
Service Code
|
NDC 0002-3238-30
|
| Hospital Charge Code |
1711822
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.87
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.71
|
| Rate for Payer: Heritage Provider Network Senior |
$10.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.86
|
|
|
ATOMOXETINE 18 MG CAPSULE [34445]
|
Facility
|
OP
|
$15.82
|
|
|
Service Code
|
NDC 0002-3238-30
|
| Hospital Charge Code |
1711822
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.86
|
| Rate for Payer: Blue Shield of California Commercial |
$9.82
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.45
|
| Rate for Payer: Dignity Health Senior |
$13.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.79
|
| Rate for Payer: Heritage Provider Network Senior |
$9.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.33
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.45
|
| Rate for Payer: Vantage Medical Group Senior |
$13.45
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-11
|
| Hospital Charge Code |
1711823
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.02
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.98
|
| Rate for Payer: Heritage Provider Network Senior |
$2.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-21
|
| Hospital Charge Code |
1711823
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.74
|
| Rate for Payer: Dignity Health Senior |
$3.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.72
|
| Rate for Payer: Heritage Provider Network Senior |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Senior |
$1.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.74
|
| Rate for Payer: Vantage Medical Group Senior |
$3.74
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-21
|
| Hospital Charge Code |
1711823
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.02
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.98
|
| Rate for Payer: Heritage Provider Network Senior |
$2.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-11
|
| Hospital Charge Code |
1711823
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.74
|
| Rate for Payer: Dignity Health Senior |
$3.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.72
|
| Rate for Payer: Heritage Provider Network Senior |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Senior |
$1.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.74
|
| Rate for Payer: Vantage Medical Group Senior |
$3.74
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
IP
|
$7.59
|
|
|
Service Code
|
NDC 60687-326-25
|
| Hospital Charge Code |
1711824
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.14
|
| Rate for Payer: Heritage Provider Network Senior |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.69
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
IP
|
$4.83
|
|
|
Service Code
|
NDC 35573-418-30
|
| Hospital Charge Code |
1711824
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.32
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Senior |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$3.62
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
OP
|
$7.59
|
|
|
Service Code
|
NDC 60687-326-95
|
| Hospital Charge Code |
1711824
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$6.45 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.71
|
| Rate for Payer: Blue Shield of California EPN |
$4.46
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.45
|
| Rate for Payer: Dignity Health Senior |
$6.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.70
|
| Rate for Payer: Heritage Provider Network Senior |
$4.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.04
|
| Rate for Payer: TriValley Medical Group Senior |
$3.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.45
|
| Rate for Payer: Vantage Medical Group Senior |
$6.45
|
|
