|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
|
OP
|
$2,072.77
|
|
|
Service Code
|
CPT J0875
|
| Hospital Charge Code |
ERX206124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,140.02 |
| Max. Negotiated Rate |
$1,554.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,243.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,243.66
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,243.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,243.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,140.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,554.58
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$6.91 |
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.48
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.57
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.71
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.18
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.48
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.71
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.18
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.18
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.18
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$67.20 |
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$50.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$63.00
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$50.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$50.40
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$50.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$63.00
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
IP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,063.66 |
| Max. Negotiated Rate |
$3,001.68 |
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,001.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,251.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,063.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,814.08
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
OP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,063.66 |
| Max. Negotiated Rate |
$2,814.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,251.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,251.26
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,251.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2,251.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,063.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,814.08
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.73
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.46
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.73
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.46
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 0527-3220-37
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.18
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 0527-3220-37
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.18
|
|
