|
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 |
$1.77 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.20
|
| 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 Exchange |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Central Health Plan Commercial |
$1.58
|
| 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: Health Management Network EPO/PPO |
$1.77
|
| 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 |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
| Rate for Payer: Riverside University Health System MISP |
$0.79
|
| 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 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$51.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Blue Shield of California Commercial |
$53.26
|
| Rate for Payer: Blue Shield of California EPN |
$33.52
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: Cigna of CA HMO |
$58.80
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$58.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$53.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Riverside University Health System MISP |
$33.60
|
| 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 |
$31.53
|
| Rate for Payer: United Healthcare All Other HMO |
$30.69
|
| Rate for Payer: United Healthcare HMO Rider |
$30.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.51
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Blue Shield of California Commercial |
$67.37
|
| Rate for Payer: Blue Shield of California EPN |
$42.34
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: Cigna of CA HMO |
$58.80
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$58.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$53.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.53
|
| Rate for Payer: United Healthcare All Other HMO |
$30.69
|
| Rate for Payer: United Healthcare HMO Rider |
$30.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.51
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
IP
|
$4,215.86
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$843.17 |
| Max. Negotiated Rate |
$3,794.27 |
| Rate for Payer: Adventist Health Commercial |
$843.17
|
| Rate for Payer: Blue Shield of California Commercial |
$3,381.12
|
| Rate for Payer: Blue Shield of California EPN |
$2,124.79
|
| Rate for Payer: Cash Price |
$1,897.14
|
| Rate for Payer: Central Health Plan Commercial |
$3,372.69
|
| Rate for Payer: Cigna of CA HMO |
$2,951.10
|
| Rate for Payer: Cigna of CA PPO |
$2,951.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,951.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,686.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1,686.34
|
| Rate for Payer: Galaxy Health WC |
$3,583.48
|
| Rate for Payer: Global Benefits Group Commercial |
$2,529.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,794.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,677.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,487.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$843.17
|
| Rate for Payer: Multiplan Commercial |
$3,161.89
|
| Rate for Payer: Networks By Design Commercial |
$2,107.93
|
| Rate for Payer: Prime Health Services Commercial |
$3,583.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,582.21
|
| Rate for Payer: United Healthcare All Other HMO |
$1,540.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1,506.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,380.69
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
OP
|
$4,215.86
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$843.17 |
| Max. Negotiated Rate |
$3,794.27 |
| Rate for Payer: Adventist Health Commercial |
$843.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,560.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,583.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,318.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,161.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,041.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,452.37
|
| Rate for Payer: Blue Shield of California Commercial |
$2,672.86
|
| Rate for Payer: Blue Shield of California EPN |
$1,682.13
|
| Rate for Payer: Cash Price |
$1,897.14
|
| Rate for Payer: Central Health Plan Commercial |
$3,372.69
|
| Rate for Payer: Cigna of CA HMO |
$2,951.10
|
| Rate for Payer: Cigna of CA PPO |
$2,951.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,583.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,583.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,583.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,951.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,686.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1,686.34
|
| Rate for Payer: Galaxy Health WC |
$3,583.48
|
| Rate for Payer: Global Benefits Group Commercial |
$2,529.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,794.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,677.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,530.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,487.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$843.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,951.10
|
| Rate for Payer: Multiplan Commercial |
$3,161.89
|
| Rate for Payer: Networks By Design Commercial |
$2,107.93
|
| Rate for Payer: Prime Health Services Commercial |
$3,583.48
|
| Rate for Payer: Riverside University Health System MISP |
$1,686.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,529.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,529.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,582.21
|
| Rate for Payer: United Healthcare All Other HMO |
$1,540.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1,506.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,380.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,583.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,583.48
|
| Rate for Payer: Vantage Medical Group Senior |
$3,583.48
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 4988436201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Central Health Plan Commercial |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
| Rate for Payer: Riverside University Health System MISP |
$0.31
|
| 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
|
$0.78
|
|
|
Service Code
|
NDC 4988436201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Central Health Plan Commercial |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| 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
|
$1.95
|
|
|
Service Code
|
NDC 6808430021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.56
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
| Rate for Payer: Riverside University Health System MISP |
$0.78
|
| 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
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 6808430021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.56
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115441101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| 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
|
$0.97
|
|
|
Service Code
|
NDC 0115441101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Riverside University Health System MISP |
$0.39
|
| 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 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 0115442201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Central Health Plan Commercial |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.41
|
| 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 |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| 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
|
$1.57
|
|
|
Service Code
|
NDC 0115442201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Central Health Plan Commercial |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Senior |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.41
|
| 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 |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.63
|
| 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 4988436301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| 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 4988436301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994080262
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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 9994080262
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| 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 10 MG TABLET [204693]
|
Facility
|
OP
|
$15.11
|
|
|
Service Code
|
NDC 0310621030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$13.60 |
| Rate for Payer: Adventist Health Commercial |
$3.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.79
|
| Rate for Payer: Blue Shield of California Commercial |
$9.58
|
| Rate for Payer: Blue Shield of California EPN |
$6.03
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Central Health Plan Commercial |
$12.09
|
| Rate for Payer: Cigna of CA HMO |
$10.58
|
| Rate for Payer: Cigna of CA PPO |
$10.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.04
|
| Rate for Payer: EPIC Health Plan Senior |
$6.04
|
| Rate for Payer: Galaxy Health WC |
$12.84
|
| Rate for Payer: Global Benefits Group Commercial |
$9.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.58
|
| Rate for Payer: Multiplan Commercial |
$11.33
|
| Rate for Payer: Networks By Design Commercial |
$9.82
|
| Rate for Payer: Prime Health Services Commercial |
$12.84
|
| Rate for Payer: Riverside University Health System MISP |
$6.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.55
|
| Rate for Payer: United Healthcare All Other HMO |
$7.55
|
| Rate for Payer: United Healthcare HMO Rider |
$7.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.84
|
| Rate for Payer: Vantage Medical Group Senior |
$12.84
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0781599031
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
IP
|
$15.11
|
|
|
Service Code
|
NDC 0310621039
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$13.60 |
| Rate for Payer: Adventist Health Commercial |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$12.12
|
| Rate for Payer: Blue Shield of California EPN |
$7.62
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Central Health Plan Commercial |
$12.09
|
| Rate for Payer: Cigna of CA HMO |
$10.58
|
| Rate for Payer: Cigna of CA PPO |
$10.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.04
|
| Rate for Payer: EPIC Health Plan Senior |
$6.04
|
| Rate for Payer: Galaxy Health WC |
$12.84
|
| Rate for Payer: Global Benefits Group Commercial |
$9.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$11.33
|
| Rate for Payer: Networks By Design Commercial |
$9.82
|
| Rate for Payer: Prime Health Services Commercial |
$12.84
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
OP
|
$15.14
|
|
|
Service Code
|
NDC 6699345730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$13.63 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.81
|
| Rate for Payer: Blue Shield of California Commercial |
$9.60
|
| Rate for Payer: Blue Shield of California EPN |
$6.04
|
| Rate for Payer: Cash Price |
$6.81
|
| Rate for Payer: Central Health Plan Commercial |
$12.11
|
| Rate for Payer: Cigna of CA HMO |
$10.60
|
| Rate for Payer: Cigna of CA PPO |
$10.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: EPIC Health Plan Senior |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$12.87
|
| Rate for Payer: Global Benefits Group Commercial |
$9.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.60
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
| Rate for Payer: Networks By Design Commercial |
$9.84
|
| Rate for Payer: Prime Health Services Commercial |
$12.87
|
| Rate for Payer: Riverside University Health System MISP |
$6.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.57
|
| Rate for Payer: United Healthcare All Other HMO |
$7.57
|
| Rate for Payer: United Healthcare HMO Rider |
$7.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.87
|
| Rate for Payer: Vantage Medical Group Senior |
$12.87
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 2724115201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 2724115201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Riverside University Health System MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
IP
|
$15.14
|
|
|
Service Code
|
NDC 6699345730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$13.63 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$12.14
|
| Rate for Payer: Blue Shield of California EPN |
$7.63
|
| Rate for Payer: Cash Price |
$6.81
|
| Rate for Payer: Central Health Plan Commercial |
$12.11
|
| Rate for Payer: Cigna of CA HMO |
$10.60
|
| Rate for Payer: Cigna of CA PPO |
$10.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: EPIC Health Plan Senior |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$12.87
|
| Rate for Payer: Global Benefits Group Commercial |
$9.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
| Rate for Payer: Networks By Design Commercial |
$9.84
|
| Rate for Payer: Prime Health Services Commercial |
$12.87
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
IP
|
$15.11
|
|
|
Service Code
|
NDC 0310621030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$13.60 |
| Rate for Payer: Adventist Health Commercial |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$12.12
|
| Rate for Payer: Blue Shield of California EPN |
$7.62
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Central Health Plan Commercial |
$12.09
|
| Rate for Payer: Cigna of CA HMO |
$10.58
|
| Rate for Payer: Cigna of CA PPO |
$10.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.04
|
| Rate for Payer: EPIC Health Plan Senior |
$6.04
|
| Rate for Payer: Galaxy Health WC |
$12.84
|
| Rate for Payer: Global Benefits Group Commercial |
$9.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$11.33
|
| Rate for Payer: Networks By Design Commercial |
$9.82
|
| Rate for Payer: Prime Health Services Commercial |
$12.84
|
|
