|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$5.62
|
| Rate for Payer: Blue Shield of California EPN |
$3.70
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: Adventist Health Commercial |
$1.73
|
| Rate for Payer: Blue Shield of California Commercial |
$6.38
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Senior |
$3.46
|
| Rate for Payer: Galaxy Health WC |
$7.34
|
| Rate for Payer: Global Benefits Group Commercial |
$5.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$6.91
|
| Rate for Payer: Networks By Design Commercial |
$5.62
|
| Rate for Payer: Prime Health Services Commercial |
$7.34
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.67
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.33
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.81
|
| Rate for Payer: United Healthcare All Other HMO |
$3.81
|
| Rate for Payer: United Healthcare HMO Rider |
$3.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: Adventist Health Commercial |
$1.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.31
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Senior |
$3.46
|
| Rate for Payer: Galaxy Health WC |
$7.34
|
| Rate for Payer: Global Benefits Group Commercial |
$5.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$6.91
|
| Rate for Payer: Networks By Design Commercial |
$5.62
|
| Rate for Payer: Prime Health Services Commercial |
$7.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO |
$4.32
|
| Rate for Payer: United Healthcare HMO Rider |
$4.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.34
|
| Rate for Payer: Vantage Medical Group Senior |
$7.34
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 49884-364-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.21
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Senior |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO |
$0.99
|
| Rate for Payer: United Healthcare HMO Rider |
$0.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Senior |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 49884-364-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$55.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$51.58
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna of CA HMO |
$53.76
|
| Rate for Payer: Cigna of CA PPO |
$62.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Networks By Design Commercial |
$54.60
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$50.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.00
|
| Rate for Payer: United Healthcare All Other HMO |
$42.00
|
| Rate for Payer: United Healthcare HMO Rider |
$42.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Blue Shield of California Commercial |
$61.99
|
| Rate for Payer: Blue Shield of California EPN |
$40.82
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.16
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Networks By Design Commercial |
$54.60
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 49884-362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 49884-362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.28
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO |
$0.98
|
| Rate for Payer: United Healthcare HMO Rider |
$0.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| 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: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| 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 HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
IP
|
$15.14
|
|
|
Service Code
|
NDC 66993-457-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$12.87 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$11.17
|
| Rate for Payer: Blue Shield of California EPN |
$7.36
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO |
$10.60
|
| Rate for Payer: Cigna of CA PPO |
$10.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: EPIC Health Plan Senior |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$12.87
|
| Rate for Payer: Global Benefits Group Commercial |
$9.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Multiplan Commercial |
$12.11
|
| Rate for Payer: Networks By Design Commercial |
$9.84
|
| Rate for Payer: Prime Health Services Commercial |
$12.87
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
OP
|
$15.14
|
|
|
Service Code
|
NDC 66993-457-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$12.87 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.30
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO |
$10.60
|
| Rate for Payer: Cigna of CA PPO |
$10.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: EPIC Health Plan Senior |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$12.87
|
| Rate for Payer: Global Benefits Group Commercial |
$9.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.60
|
| Rate for Payer: Multiplan Commercial |
$12.11
|
| Rate for Payer: Networks By Design Commercial |
$9.84
|
| Rate for Payer: Prime Health Services Commercial |
$12.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.57
|
| Rate for Payer: United Healthcare All Other HMO |
$7.57
|
| Rate for Payer: United Healthcare HMO Rider |
$7.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.87
|
| Rate for Payer: Vantage Medical Group Senior |
$12.87
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
IP
|
$23.99
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$20.39 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Blue Shield of California Commercial |
$17.70
|
| Rate for Payer: Blue Shield of California EPN |
$11.66
|
| Rate for Payer: Cash Price |
$13.19
|
| Rate for Payer: Cigna of CA HMO |
$16.79
|
| Rate for Payer: Cigna of CA PPO |
$16.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Senior |
$9.60
|
| Rate for Payer: Galaxy Health WC |
$20.39
|
| Rate for Payer: Global Benefits Group Commercial |
$14.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
| Rate for Payer: Multiplan Commercial |
$19.19
|
| Rate for Payer: Networks By Design Commercial |
$15.59
|
| Rate for Payer: Prime Health Services Commercial |
$20.39
|
|
