|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.71
|
| 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: 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: 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 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$71.40 |
| 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 |
$46.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.05
|
| Rate for Payer: Blue Distinction Transplant |
$50.40
|
| Rate for Payer: Blue Shield of California Commercial |
$61.91
|
| Rate for Payer: Blue Shield of California EPN |
$49.06
|
| Rate for Payer: Cash Price |
$37.80
|
| 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 Media |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$63.00
|
| 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: 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
|
| 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 |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Blue Shield of California Commercial |
$59.81
|
| Rate for Payer: Blue Shield of California EPN |
$43.01
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
OP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$900.50 |
| Max. Negotiated Rate |
$3,189.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,461.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,189.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,063.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,063.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,235.50
|
| Rate for Payer: Blue Distinction Transplant |
$2,251.26
|
| Rate for Payer: Blue Shield of California Commercial |
$2,765.30
|
| Rate for Payer: Blue Shield of California EPN |
$2,191.23
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cigna of CA HMO |
$2,626.47
|
| Rate for Payer: Cigna of CA PPO |
$2,626.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,189.28
|
| Rate for Payer: Dignity Health Media |
$3,189.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,189.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,500.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,500.84
|
| Rate for Payer: Galaxy Health WC |
$3,189.28
|
| Rate for Payer: Global Benefits Group Commercial |
$2,251.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,814.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,502.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,429.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$900.50
|
| Rate for Payer: Multiplan Commercial |
$3,001.68
|
| Rate for Payer: Networks By Design Commercial |
$1,876.05
|
| Rate for Payer: Prime Health Services Commercial |
$3,189.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,251.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,251.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,876.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1,876.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1,876.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,876.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,189.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,189.28
|
| Rate for Payer: Vantage Medical Group Senior |
$3,189.28
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
IP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$900.50 |
| Max. Negotiated Rate |
$3,189.28 |
| Rate for Payer: Blue Shield of California Commercial |
$2,671.50
|
| Rate for Payer: Blue Shield of California EPN |
$1,921.08
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cigna of CA HMO |
$2,626.47
|
| Rate for Payer: Cigna of CA PPO |
$2,626.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,500.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,500.84
|
| Rate for Payer: Galaxy Health WC |
$3,189.28
|
| Rate for Payer: Global Benefits Group Commercial |
$2,251.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,502.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,429.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$900.50
|
| Rate for Payer: Multiplan Commercial |
$3,001.68
|
| Rate for Payer: Networks By Design Commercial |
$1,876.05
|
| Rate for Payer: Prime Health Services Commercial |
$3,189.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,416.79
|
| Rate for Payer: United Healthcare All Other HMO |
$1,383.77
|
| Rate for Payer: United Healthcare HMO Rider |
$1,353.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,238.19
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.35
|
| 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: 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: 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
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| 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 |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: Blue Distinction Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.44
|
| 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 Media |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.73
|
| 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: 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
|
| 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
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.44
|
| 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: 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: 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 |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.66 |
| 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 |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.16
|
| Rate for Payer: Blue Distinction Transplant |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$0.88
|
| 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 Media |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.46
|
| 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: 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
|
| 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 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.66 |
| 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 |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: Blue Distinction Transplant |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| 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 Media |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.59
|
| 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: 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
|
| 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 |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.88
|
| 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: 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: 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 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.33 |
| 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 |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Distinction Transplant |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.71
|
| 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 Media |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.18
|
| 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: 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
|
| 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
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.57
|
| 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: 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: 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
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| 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 |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Distinction Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 Media |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.95
|
| 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: 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
|
| 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 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 0527-3220-37
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| 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 |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Distinction Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 Media |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.95
|
| 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: 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
|
| 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 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 0527-3220-37
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.57
|
| 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: 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: 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
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.71
|
| 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: 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: 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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| Hospital Charge Code |
1715985
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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: 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: 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 |
1715985
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Distinction Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| 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: 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
|
| 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
|
$22.61
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
ERX204693
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Blue Shield of California Commercial |
$16.10
|
| Rate for Payer: Blue Shield of California EPN |
$11.58
|
| Rate for Payer: Cash Price |
$10.17
|
| Rate for Payer: Cigna of CA HMO |
$15.83
|
| Rate for Payer: Cigna of CA PPO |
$15.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.04
|
| Rate for Payer: Galaxy Health WC |
$19.22
|
| Rate for Payer: Global Benefits Group Commercial |
$13.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$18.09
|
| Rate for Payer: Networks By Design Commercial |
$14.70
|
| Rate for Payer: Prime Health Services Commercial |
$19.22
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
OP
|
$22.61
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
ERX204693
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.47
|
| Rate for Payer: Blue Distinction Transplant |
$13.57
|
| Rate for Payer: Blue Shield of California Commercial |
$16.66
|
| Rate for Payer: Blue Shield of California EPN |
$13.20
|
| Rate for Payer: Cash Price |
$10.17
|
| Rate for Payer: Cigna of CA HMO |
$15.83
|
| Rate for Payer: Cigna of CA PPO |
$15.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.22
|
| Rate for Payer: Dignity Health Media |
$19.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.04
|
| Rate for Payer: Galaxy Health WC |
$19.22
|
| Rate for Payer: Global Benefits Group Commercial |
$13.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$18.09
|
| Rate for Payer: Networks By Design Commercial |
$14.70
|
| Rate for Payer: Prime Health Services Commercial |
$19.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.30
|
| Rate for Payer: United Healthcare All Other HMO |
$11.30
|
| Rate for Payer: United Healthcare HMO Rider |
$11.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.22
|
| Rate for Payer: Vantage Medical Group Senior |
$19.22
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
1711546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
1711546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Distinction Transplant |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Media |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 69543-150-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Galaxy Health WC |
$1.00
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.00
|
|
