|
DABRAFENIB 50 MG CAPSULE [202199]
|
Facility
|
IP
|
$130.62
|
|
|
Service Code
|
NDC 0078068266
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.12 |
| Max. Negotiated Rate |
$111.03 |
| Rate for Payer: Adventist Health Commercial |
$26.12
|
| Rate for Payer: Blue Shield of California Commercial |
$100.45
|
| Rate for Payer: Blue Shield of California Commercial |
$66.22
|
| Rate for Payer: Cash Price |
$58.78
|
| Rate for Payer: Cigna of CA HMO |
$91.43
|
| Rate for Payer: Cigna of CA PPO |
$91.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$91.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.25
|
| Rate for Payer: EPIC Health Plan Senior |
$52.25
|
| Rate for Payer: Galaxy Health WC |
$111.03
|
| Rate for Payer: Global Benefits Group Commercial |
$78.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$82.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$77.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.35
|
| Rate for Payer: Multiplan Commercial |
$104.50
|
| Rate for Payer: Networks By Design Commercial |
$84.90
|
| Rate for Payer: Prime Health Services Commercial |
$111.03
|
|
|
DABRAFENIB 75 MG CAPSULE [202200]
|
Facility
|
OP
|
$168.34
|
|
|
Service Code
|
NDC 0078068166
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$143.09 |
| Rate for Payer: Adventist Health Commercial |
$33.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$110.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$143.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$92.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$126.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$108.02
|
| Rate for Payer: Cash Price |
$75.75
|
| Rate for Payer: Cigna of CA HMO |
$117.84
|
| Rate for Payer: Cigna of CA PPO |
$117.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$143.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$143.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$143.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$117.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.34
|
| Rate for Payer: EPIC Health Plan Senior |
$67.34
|
| Rate for Payer: Galaxy Health WC |
$143.09
|
| Rate for Payer: Global Benefits Group Commercial |
$101.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$106.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$99.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$117.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$117.84
|
| Rate for Payer: Multiplan Commercial |
$134.67
|
| Rate for Payer: Networks By Design Commercial |
$109.42
|
| Rate for Payer: Prime Health Services Commercial |
$143.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$101.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$101.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$84.17
|
| Rate for Payer: United Healthcare All Other HMO |
$84.17
|
| Rate for Payer: United Healthcare HMO Rider |
$84.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$84.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$143.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$143.09
|
| Rate for Payer: Vantage Medical Group Senior |
$143.09
|
|
|
DABRAFENIB 75 MG CAPSULE [202200]
|
Facility
|
IP
|
$168.34
|
|
|
Service Code
|
NDC 0078068166
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$143.09 |
| Rate for Payer: Adventist Health Commercial |
$33.67
|
| Rate for Payer: Blue Shield of California Commercial |
$129.45
|
| Rate for Payer: Blue Shield of California Commercial |
$85.35
|
| Rate for Payer: Cash Price |
$75.75
|
| Rate for Payer: Cigna of CA HMO |
$117.84
|
| Rate for Payer: Cigna of CA PPO |
$117.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$117.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.34
|
| Rate for Payer: EPIC Health Plan Senior |
$67.34
|
| Rate for Payer: Galaxy Health WC |
$143.09
|
| Rate for Payer: Global Benefits Group Commercial |
$101.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$106.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$99.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.40
|
| Rate for Payer: Multiplan Commercial |
$134.67
|
| Rate for Payer: Networks By Design Commercial |
$109.42
|
| Rate for Payer: Prime Health Services Commercial |
$143.09
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
OP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$32.79 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.79
|
| Rate for Payer: Blue Shield of California Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Cigna of CA HMO |
$10.41
|
| Rate for Payer: Cigna of CA PPO |
$10.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$12.64
|
| Rate for Payer: Global Benefits Group Commercial |
$8.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.41
|
| Rate for Payer: Multiplan Commercial |
$11.90
|
| Rate for Payer: Networks By Design Commercial |
$7.43
|
| Rate for Payer: Prime Health Services Commercial |
$12.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.64
|
| Rate for Payer: Vantage Medical Group Senior |
$12.64
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
IP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$12.64 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Blue Shield of California Commercial |
$11.44
|
| Rate for Payer: Blue Shield of California Commercial |
$7.54
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Cigna of CA HMO |
$10.41
|
| Rate for Payer: Cigna of CA PPO |
$10.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$12.64
|
| Rate for Payer: Global Benefits Group Commercial |
$8.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
| Rate for Payer: Multiplan Commercial |
$11.90
|
| Rate for Payer: Networks By Design Commercial |
$7.43
|
| Rate for Payer: Prime Health Services Commercial |
$12.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.87
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
IP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$11.07
|
| Rate for Payer: Blue Shield of California Commercial |
$7.30
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$11.52
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
OP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$32.79 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.79
|
| Rate for Payer: Blue Shield of California Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$11.52
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
IP
|
$693.42
|
|
|
Service Code
|
NDC 0069019730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$589.41 |
| Rate for Payer: Adventist Health Commercial |
$138.68
|
| Rate for Payer: Blue Shield of California Commercial |
$351.56
|
| Rate for Payer: Blue Shield of California Commercial |
$533.24
|
| Rate for Payer: Cash Price |
$312.04
|
| Rate for Payer: Cigna of CA HMO |
$485.39
|
| Rate for Payer: Cigna of CA PPO |
$485.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$485.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.37
|
| Rate for Payer: EPIC Health Plan Senior |
$277.37
|
| Rate for Payer: Galaxy Health WC |
$589.41
|
| Rate for Payer: Global Benefits Group Commercial |
$416.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$440.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$409.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.42
|
| Rate for Payer: Multiplan Commercial |
$554.74
|
| Rate for Payer: Networks By Design Commercial |
$450.72
|
| Rate for Payer: Prime Health Services Commercial |
$589.41
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
OP
|
$693.42
|
|
|
Service Code
|
NDC 0069019730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$589.41 |
| Rate for Payer: Adventist Health Commercial |
$138.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$454.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$589.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$381.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$520.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$444.97
|
| Rate for Payer: Cash Price |
$312.04
|
| Rate for Payer: Cigna of CA HMO |
$485.39
|
| Rate for Payer: Cigna of CA PPO |
$485.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$589.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$589.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$589.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$485.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.37
|
| Rate for Payer: EPIC Health Plan Senior |
$277.37
|
| Rate for Payer: Galaxy Health WC |
$589.41
|
| Rate for Payer: Global Benefits Group Commercial |
$416.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$440.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$251.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$409.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$485.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$485.39
|
| Rate for Payer: Multiplan Commercial |
$554.74
|
| Rate for Payer: Networks By Design Commercial |
$450.72
|
| Rate for Payer: Prime Health Services Commercial |
$589.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$416.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$416.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$346.71
|
| Rate for Payer: United Healthcare All Other HMO |
$346.71
|
| Rate for Payer: United Healthcare HMO Rider |
$346.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$346.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$589.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$589.41
|
| Rate for Payer: Vantage Medical Group Senior |
$589.41
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
IP
|
$693.42
|
|
|
Service Code
|
NDC 0069119830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$589.41 |
| Rate for Payer: Adventist Health Commercial |
$138.68
|
| Rate for Payer: Blue Shield of California Commercial |
$351.56
|
| Rate for Payer: Blue Shield of California Commercial |
$533.24
|
| Rate for Payer: Cash Price |
$312.04
|
| Rate for Payer: Cigna of CA HMO |
$485.39
|
| Rate for Payer: Cigna of CA PPO |
$485.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$485.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.37
|
| Rate for Payer: EPIC Health Plan Senior |
$277.37
|
| Rate for Payer: Galaxy Health WC |
$589.41
|
| Rate for Payer: Global Benefits Group Commercial |
$416.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$440.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$409.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.42
|
| Rate for Payer: Multiplan Commercial |
$554.74
|
| Rate for Payer: Networks By Design Commercial |
$450.72
|
| Rate for Payer: Prime Health Services Commercial |
$589.41
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
OP
|
$693.42
|
|
|
Service Code
|
NDC 0069119830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$589.41 |
| Rate for Payer: Adventist Health Commercial |
$138.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$454.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$589.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$381.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$520.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$444.97
|
| Rate for Payer: Cash Price |
$312.04
|
| Rate for Payer: Cigna of CA HMO |
$485.39
|
| Rate for Payer: Cigna of CA PPO |
$485.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$589.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$589.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$589.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$485.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.37
|
| Rate for Payer: EPIC Health Plan Senior |
$277.37
|
| Rate for Payer: Galaxy Health WC |
$589.41
|
| Rate for Payer: Global Benefits Group Commercial |
$416.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$440.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$251.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$409.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$485.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$485.39
|
| Rate for Payer: Multiplan Commercial |
$554.74
|
| Rate for Payer: Networks By Design Commercial |
$450.72
|
| Rate for Payer: Prime Health Services Commercial |
$589.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$416.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$416.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$346.71
|
| Rate for Payer: United Healthcare All Other HMO |
$346.71
|
| Rate for Payer: United Healthcare HMO Rider |
$346.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$346.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$589.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$589.41
|
| Rate for Payer: Vantage Medical Group Senior |
$589.41
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
IP
|
$693.42
|
|
|
Service Code
|
NDC 0069229930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$589.41 |
| Rate for Payer: Adventist Health Commercial |
$138.68
|
| Rate for Payer: Blue Shield of California Commercial |
$351.56
|
| Rate for Payer: Blue Shield of California Commercial |
$533.24
|
| Rate for Payer: Cash Price |
$312.04
|
| Rate for Payer: Cigna of CA HMO |
$485.39
|
| Rate for Payer: Cigna of CA PPO |
$485.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$485.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.37
|
| Rate for Payer: EPIC Health Plan Senior |
$277.37
|
| Rate for Payer: Galaxy Health WC |
$589.41
|
| Rate for Payer: Global Benefits Group Commercial |
$416.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$440.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$409.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.42
|
| Rate for Payer: Multiplan Commercial |
$554.74
|
| Rate for Payer: Networks By Design Commercial |
$450.72
|
| Rate for Payer: Prime Health Services Commercial |
$589.41
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
OP
|
$693.42
|
|
|
Service Code
|
NDC 0069229930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$589.41 |
| Rate for Payer: Adventist Health Commercial |
$138.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$454.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$589.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$381.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$520.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$444.97
|
| Rate for Payer: Cash Price |
$312.04
|
| Rate for Payer: Cigna of CA HMO |
$485.39
|
| Rate for Payer: Cigna of CA PPO |
$485.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$589.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$589.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$589.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$485.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.37
|
| Rate for Payer: EPIC Health Plan Senior |
$277.37
|
| Rate for Payer: Galaxy Health WC |
$589.41
|
| Rate for Payer: Global Benefits Group Commercial |
$416.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$440.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$251.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$409.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$485.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$485.39
|
| Rate for Payer: Multiplan Commercial |
$554.74
|
| Rate for Payer: Networks By Design Commercial |
$450.72
|
| Rate for Payer: Prime Health Services Commercial |
$589.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$416.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$416.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$346.71
|
| Rate for Payer: United Healthcare All Other HMO |
$346.71
|
| Rate for Payer: United Healthcare HMO Rider |
$346.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$346.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$589.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$589.41
|
| Rate for Payer: Vantage Medical Group Senior |
$589.41
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
OP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.13 |
| Max. Negotiated Rate |
$885.00 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$568.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$461.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$338.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$307.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$31.13
|
| Rate for Payer: Blue Shield of California Commercial |
$885.00
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$384.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$338.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$338.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$619.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$507.23
|
| Rate for Payer: EPIC Health Plan Senior |
$338.15
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$504.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$307.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$307.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$561.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$585.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$430.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$387.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$411.93
|
| Rate for Payer: Multiplan Commercial |
$708.00
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$531.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$531.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$332.14
|
| Rate for Payer: United Healthcare All Other HMO |
$323.29
|
| Rate for Payer: United Healthcare HMO Rider |
$316.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$289.84
|
| Rate for Payer: Upland Medical Group Pediatric |
$307.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$384.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$338.15
|
| Rate for Payer: Vantage Medical Group Senior |
$338.15
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
IP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.00 |
| Max. Negotiated Rate |
$752.25 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Blue Shield of California Commercial |
$448.69
|
| Rate for Payer: Blue Shield of California Commercial |
$680.57
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$619.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$354.00
|
| Rate for Payer: EPIC Health Plan Senior |
$354.00
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$561.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$522.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$708.00
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$332.14
|
| Rate for Payer: United Healthcare All Other HMO |
$323.29
|
| Rate for Payer: United Healthcare HMO Rider |
$316.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$289.84
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
|
OP
|
$2,134.96
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.29 |
| Max. Negotiated Rate |
$1,814.72 |
| Rate for Payer: Vantage Medical Group Senior |
$12.42
|
| Rate for Payer: Adventist Health Commercial |
$426.99
|
| Rate for Payer: Adventist Health Commercial |
$384.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$97.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$97.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.09
|
| Rate for Payer: Blue Shield of California Commercial |
$21.35
|
| Rate for Payer: Blue Shield of California Commercial |
$21.35
|
| Rate for Payer: Cash Price |
$864.66
|
| Rate for Payer: Cash Price |
$960.73
|
| Rate for Payer: Cash Price |
$864.66
|
| Rate for Payer: Cash Price |
$960.73
|
| Rate for Payer: Cigna of CA HMO |
$1,494.47
|
| Rate for Payer: Cigna of CA HMO |
$1,345.02
|
| Rate for Payer: Cigna of CA PPO |
$1,494.47
|
| Rate for Payer: Cigna of CA PPO |
$1,345.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,345.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,494.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.63
|
| Rate for Payer: EPIC Health Plan Senior |
$12.42
|
| Rate for Payer: EPIC Health Plan Senior |
$12.42
|
| Rate for Payer: Galaxy Health WC |
$1,633.24
|
| Rate for Payer: Galaxy Health WC |
$1,814.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1,152.88
|
| Rate for Payer: Global Benefits Group Commercial |
$1,280.98
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.52
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,220.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,355.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$512.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$1,537.17
|
| Rate for Payer: Multiplan Commercial |
$1,707.97
|
| Rate for Payer: Networks By Design Commercial |
$1,067.48
|
| Rate for Payer: Networks By Design Commercial |
$960.73
|
| Rate for Payer: Prime Health Services Commercial |
$1,633.24
|
| Rate for Payer: Prime Health Services Commercial |
$1,814.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,280.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,152.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,152.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,280.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$801.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.12
|
| Rate for Payer: United Healthcare All Other HMO |
$701.91
|
| Rate for Payer: United Healthcare All Other HMO |
$779.90
|
| Rate for Payer: United Healthcare HMO Rider |
$686.73
|
| Rate for Payer: United Healthcare HMO Rider |
$763.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$699.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.28
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.29
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.42
|
| Rate for Payer: Vantage Medical Group Senior |
$12.42
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
|
IP
|
$2,134.96
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$426.99 |
| Max. Negotiated Rate |
$1,814.72 |
| Rate for Payer: Adventist Health Commercial |
$426.99
|
| Rate for Payer: Adventist Health Commercial |
$384.29
|
| Rate for Payer: Blue Shield of California Commercial |
$974.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1,082.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1,641.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1,477.60
|
| Rate for Payer: Cash Price |
$864.66
|
| Rate for Payer: Cash Price |
$960.73
|
| Rate for Payer: Cigna of CA HMO |
$1,494.47
|
| Rate for Payer: Cigna of CA HMO |
$1,345.02
|
| Rate for Payer: Cigna of CA PPO |
$1,345.02
|
| Rate for Payer: Cigna of CA PPO |
$1,494.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,345.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,494.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$768.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$853.98
|
| Rate for Payer: EPIC Health Plan Senior |
$768.58
|
| Rate for Payer: EPIC Health Plan Senior |
$853.98
|
| Rate for Payer: Galaxy Health WC |
$1,633.24
|
| Rate for Payer: Galaxy Health WC |
$1,814.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1,280.98
|
| Rate for Payer: Global Benefits Group Commercial |
$1,152.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,220.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,355.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,133.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,259.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$512.39
|
| Rate for Payer: Multiplan Commercial |
$1,537.17
|
| Rate for Payer: Multiplan Commercial |
$1,707.97
|
| Rate for Payer: Networks By Design Commercial |
$1,067.48
|
| Rate for Payer: Networks By Design Commercial |
$960.73
|
| Rate for Payer: Prime Health Services Commercial |
$1,814.72
|
| Rate for Payer: Prime Health Services Commercial |
$1,633.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$801.25
|
| Rate for Payer: United Healthcare All Other HMO |
$779.90
|
| Rate for Payer: United Healthcare All Other HMO |
$701.91
|
| Rate for Payer: United Healthcare HMO Rider |
$686.73
|
| Rate for Payer: United Healthcare HMO Rider |
$763.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$699.20
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527136906
|
| 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 |
$4.38
|
| Rate for Payer: Blue Shield of California Commercial |
$6.64
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$5.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.10
|
| 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
|
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527136901
|
| 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 |
$3.86
|
| Rate for Payer: Blue Shield of California Commercial |
$5.85
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$4.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.49
|
| 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
|
OP
|
$8.64
|
|
|
Service Code
|
NDC 0527136906
|
| 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 |
$5.54
|
| Rate for Payer: Cash Price |
$3.89
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$5.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.10
|
| 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
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527136901
|
| 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 |
$4.88
|
| Rate for Payer: Cash Price |
$3.42
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$4.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.49
|
| 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
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.58
|
|
|
Service Code
|
NDC 4988436401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$1.11
|
| Rate for Payer: Cigna of CA PPO |
$1.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.03
|
| Rate for Payer: Prime Health Services Commercial |
$1.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.95
|
| 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 |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115443301
|
| 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 |
$1.26
|
| Rate for Payer: Cash Price |
$0.89
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.16
|
| 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 0115443301
|
| 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 |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.16
|
| 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
|
IP
|
$1.58
|
|
|
Service Code
|
NDC 4988436401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$1.11
|
| Rate for Payer: Cigna of CA PPO |
$1.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.93
|
| 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 |
$1.03
|
| Rate for Payer: Prime Health Services Commercial |
$1.34
|
|
