|
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: AlphaCare Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.94
|
| 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
|
$1.57
|
|
|
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 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: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.76
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.76
|
| 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 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
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 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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$19.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.47
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$13.57
|
| 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
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: BCBS Transplant Transplant |
$0.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.87
|
| 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 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 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
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
OP
|
$2.37
|
|
|
Service Code
|
NDC 13925-504-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: BCBS Transplant Transplant |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.01
|
| Rate for Payer: Dignity Health Media |
$2.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1.18
|
| Rate for Payer: United Healthcare HMO Rider |
$1.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Vantage Medical Group Senior |
$2.01
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
IP
|
$2.37
|
|
|
Service Code
|
NDC 13925-504-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
OP
|
$2.74
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.63
|
| Rate for Payer: BCBS Transplant Transplant |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.33
|
| Rate for Payer: Dignity Health Media |
$2.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.19
|
| Rate for Payer: Networks By Design Commercial |
$1.78
|
| Rate for Payer: Prime Health Services Commercial |
$2.33
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.37
|
| Rate for Payer: United Healthcare All Other HMO |
$1.37
|
| Rate for Payer: United Healthcare HMO Rider |
$1.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.33
|
| Rate for Payer: Vantage Medical Group Senior |
$2.33
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
IP
|
$2.74
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.19
|
| Rate for Payer: Networks By Design Commercial |
$1.78
|
| Rate for Payer: Prime Health Services Commercial |
$2.33
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
OP
|
$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: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: BCBS Transplant Transplant |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| 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: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Media |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.47
|
| Rate for Payer: Galaxy Health WC |
$1.00
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.89
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.59
|
| Rate for Payer: United Healthcare All Other HMO |
$0.59
|
| Rate for Payer: United Healthcare HMO Rider |
$0.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1.00
|
|
|
DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]
|
Facility
OP
|
$2.37
|
|
|
Service Code
|
NDC 9994-0802-63
|
| Hospital Charge Code |
1715000
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: BCBS Transplant Transplant |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.01
|
| Rate for Payer: Dignity Health Media |
$2.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1.18
|
| Rate for Payer: United Healthcare HMO Rider |
$1.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Vantage Medical Group Senior |
$2.01
|
|
|
DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]
|
Facility
IP
|
$2.37
|
|
|
Service Code
|
NDC 9994-0802-63
|
| Hospital Charge Code |
1715000
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
CPT J0878
|
| Hospital Charge Code |
1720999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: BCBS Transplant Transplant |
$25.20
|
| Rate for Payer: BCBS Transplant Transplant |
$72.00
|
| Rate for Payer: Blue Shield of California Commercial |
$88.44
|
| Rate for Payer: Blue Shield of California Commercial |
$30.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Media |
$35.70
|
| Rate for Payer: Dignity Health Media |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$31.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.00
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$21.00
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| Rate for Payer: United Healthcare HMO Rider |
$21.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT J0878
|
| Hospital Charge Code |
1720999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Blue Shield of California Commercial |
$85.44
|
| Rate for Payer: Blue Shield of California Commercial |
$29.90
|
| Rate for Payer: Blue Shield of California EPN |
$61.44
|
| Rate for Payer: Blue Shield of California EPN |
$21.50
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [228045]
|
Facility
IP
|
$729.49
|
|
|
Service Code
|
CPT J9144
|
| Hospital Charge Code |
NDG228045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$175.08 |
| Max. Negotiated Rate |
$620.07 |
| Rate for Payer: Blue Shield of California Commercial |
$519.40
|
| Rate for Payer: Blue Shield of California EPN |
$373.50
|
| Rate for Payer: Cash Price |
$328.27
|
| Rate for Payer: Cigna of CA HMO |
$510.64
|
| Rate for Payer: Cigna of CA PPO |
$510.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$291.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$291.80
|
| Rate for Payer: Galaxy Health WC |
$620.07
|
| Rate for Payer: Global Benefits Group Commercial |
$437.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$486.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$277.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.08
|
| Rate for Payer: Multiplan Commercial |
$583.59
|
| Rate for Payer: Networks By Design Commercial |
$364.74
|
| Rate for Payer: Prime Health Services Commercial |
$620.07
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [228045]
|
Facility
OP
|
$729.49
|
|
|
Service Code
|
CPT J9144
|
| Hospital Charge Code |
NDG228045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.05 |
| Max. Negotiated Rate |
$620.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$96.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$53.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$53.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$89.66
|
| Rate for Payer: BCBS Transplant Transplant |
$437.69
|
| Rate for Payer: Blue Shield of California Commercial |
$537.63
|
| Rate for Payer: Blue Shield of California EPN |
$426.02
|
| Rate for Payer: Cash Price |
$328.27
|
| Rate for Payer: Cash Price |
$328.27
|
| Rate for Payer: Cigna of CA HMO |
$510.64
|
| Rate for Payer: Cigna of CA PPO |
$510.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.31
|
| Rate for Payer: Dignity Health Media |
$53.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$49.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$49.05
|
| Rate for Payer: Galaxy Health WC |
$620.07
|
| Rate for Payer: Global Benefits Group Commercial |
$437.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$547.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.44
|
| Rate for Payer: Heritage Provider Network Transplant |
$80.44
|
| Rate for Payer: IEHP Medi-Cal |
$79.46
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$79.46
|
| Rate for Payer: IEHP Medicare Advantage |
$49.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$486.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$49.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.73
|
| Rate for Payer: Multiplan Commercial |
$583.59
|
| Rate for Payer: Networks By Design Commercial |
$364.74
|
| Rate for Payer: Prime Health Services Commercial |
$620.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$437.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$437.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$364.74
|
| Rate for Payer: United Healthcare All Other HMO |
$364.74
|
| Rate for Payer: United Healthcare HMO Rider |
$364.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$364.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.96
|
| Rate for Payer: Vantage Medical Group Senior |
$53.96
|
|
|
DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION [211862]
|
Facility
IP
|
$160.56
|
|
|
Service Code
|
NDC 57894-502-05
|
| Hospital Charge Code |
NDG211862B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$136.48 |
| Rate for Payer: Blue Shield of California Commercial |
$114.32
|
| Rate for Payer: Blue Shield of California EPN |
$82.21
|
| Rate for Payer: Cash Price |
$72.25
|
| Rate for Payer: Cigna of CA HMO |
$112.39
|
| Rate for Payer: Cigna of CA PPO |
$112.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$64.22
|
| Rate for Payer: Galaxy Health WC |
$136.48
|
| Rate for Payer: Global Benefits Group Commercial |
$96.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.53
|
| Rate for Payer: Multiplan Commercial |
$128.45
|
| Rate for Payer: Networks By Design Commercial |
$80.28
|
| Rate for Payer: Prime Health Services Commercial |
$136.48
|
|
