|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
IP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$13.38 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Blue Shield of California Commercial |
$11.49
|
| Rate for Payer: Blue Shield of California EPN |
$7.49
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Central Health Plan Commercial |
$11.90
|
| Rate for Payer: Cigna of CA HMO |
$10.41
|
| Rate for Payer: Cigna of CA PPO |
$10.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$12.64
|
| Rate for Payer: Global Benefits Group Commercial |
$8.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$11.15
|
| Rate for Payer: Networks By Design Commercial |
$7.43
|
| Rate for Payer: Prime Health Services Commercial |
$12.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.87
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
IP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$12.96 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$11.13
|
| Rate for Payer: Blue Shield of California EPN |
$7.26
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Central Health Plan Commercial |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
OP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$13.19 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.92
|
| Rate for Payer: Blue Shield of California EPN |
$7.20
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Central Health Plan Commercial |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4.50
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: Riverside University Health System MISP |
$5.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$594.36 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$401.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$319.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$387.85
|
| Rate for Payer: Blue Shield of California Commercial |
$403.50
|
| Rate for Payer: Blue Shield of California EPN |
$263.50
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Central Health Plan Commercial |
$528.32
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.36
|
| Rate for Payer: InnovAge PACE Commercial |
$330.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
| Rate for Payer: Riverside University Health System MISP |
$264.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$330.20
|
| Rate for Payer: United Healthcare All Other HMO |
$330.20
|
| Rate for Payer: United Healthcare HMO Rider |
$330.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$594.36 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Blue Shield of California Commercial |
$510.49
|
| Rate for Payer: Blue Shield of California EPN |
$332.84
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Central Health Plan Commercial |
$528.32
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.08
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$594.36 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$401.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$319.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$387.85
|
| Rate for Payer: Blue Shield of California Commercial |
$403.50
|
| Rate for Payer: Blue Shield of California EPN |
$263.50
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Central Health Plan Commercial |
$528.32
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.36
|
| Rate for Payer: InnovAge PACE Commercial |
$330.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
| Rate for Payer: Riverside University Health System MISP |
$264.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$330.20
|
| Rate for Payer: United Healthcare All Other HMO |
$330.20
|
| Rate for Payer: United Healthcare HMO Rider |
$330.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$594.36 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Blue Shield of California Commercial |
$510.49
|
| Rate for Payer: Blue Shield of California EPN |
$332.84
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Central Health Plan Commercial |
$528.32
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.08
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$594.36 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Blue Shield of California Commercial |
$510.49
|
| Rate for Payer: Blue Shield of California EPN |
$332.84
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Central Health Plan Commercial |
$528.32
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.08
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$594.36 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$401.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$319.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$387.85
|
| Rate for Payer: Blue Shield of California Commercial |
$403.50
|
| Rate for Payer: Blue Shield of California EPN |
$263.50
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Central Health Plan Commercial |
$528.32
|
| Rate for Payer: Cigna of CA HMO |
$462.28
|
| Rate for Payer: Cigna of CA PPO |
$462.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$264.16
|
| Rate for Payer: EPIC Health Plan Senior |
$264.16
|
| Rate for Payer: Galaxy Health WC |
$561.34
|
| Rate for Payer: Global Benefits Group Commercial |
$396.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$594.36
|
| Rate for Payer: InnovAge PACE Commercial |
$330.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$440.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$408.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: Networks By Design Commercial |
$429.26
|
| Rate for Payer: Prime Health Services Commercial |
$561.34
|
| Rate for Payer: Riverside University Health System MISP |
$264.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$396.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$396.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$330.20
|
| Rate for Payer: United Healthcare All Other HMO |
$330.20
|
| Rate for Payer: United Healthcare HMO Rider |
$330.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
OP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.00 |
| Max. Negotiated Rate |
$1,621.76 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$302.92
|
| Rate for Payer: Aetna of CA HMO/PPO |
$537.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$454.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$333.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$302.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,621.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.72
|
| Rate for Payer: Blue Shield of California Commercial |
$973.50
|
| Rate for Payer: Blue Shield of California EPN |
$885.00
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Central Health Plan Commercial |
$708.00
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$333.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$333.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$408.95
|
| Rate for Payer: EPIC Health Plan Senior |
$302.92
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$796.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$496.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$288.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$302.92
|
| Rate for Payer: InnovAge PACE Commercial |
$454.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$617.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$302.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$405.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$405.92
|
| Rate for Payer: Multiplan Commercial |
$663.75
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$302.92
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: Prime Health Services Medicare |
$321.10
|
| Rate for Payer: Riverside University Health System MISP |
$333.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$531.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$531.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$332.14
|
| Rate for Payer: United Healthcare All Other HMO |
$323.29
|
| Rate for Payer: United Healthcare HMO Rider |
$316.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$289.84
|
| Rate for Payer: Upland Medical Group Pediatric |
$302.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$333.22
|
| Rate for Payer: Vantage Medical Group Senior |
$333.22
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
IP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.00 |
| Max. Negotiated Rate |
$796.50 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Blue Shield of California Commercial |
$684.11
|
| Rate for Payer: Blue Shield of California EPN |
$446.04
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Central Health Plan Commercial |
$708.00
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$354.00
|
| Rate for Payer: EPIC Health Plan Senior |
$354.00
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$796.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$547.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.00
|
| Rate for Payer: Multiplan Commercial |
$663.75
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$332.14
|
| Rate for Payer: United Healthcare All Other HMO |
$323.29
|
| Rate for Payer: United Healthcare HMO Rider |
$316.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$289.84
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Adventist Health Commercial |
$1.73
|
| Rate for Payer: Blue Shield of California Commercial |
$6.68
|
| Rate for Payer: Blue Shield of California EPN |
$4.35
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Central Health Plan Commercial |
$6.91
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Senior |
$3.46
|
| Rate for Payer: Galaxy Health WC |
$7.34
|
| Rate for Payer: Global Benefits Group Commercial |
$5.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
| Rate for Payer: Networks By Design Commercial |
$5.62
|
| Rate for Payer: Prime Health Services Commercial |
$7.34
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Adventist Health Commercial |
$1.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.07
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.45
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Central Health Plan Commercial |
$6.91
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Senior |
$3.46
|
| Rate for Payer: Galaxy Health WC |
$7.34
|
| Rate for Payer: Global Benefits Group Commercial |
$5.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.78
|
| Rate for Payer: InnovAge PACE Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
| Rate for Payer: Networks By Design Commercial |
$5.62
|
| Rate for Payer: Prime Health Services Commercial |
$7.34
|
| Rate for Payer: Riverside University Health System MISP |
$3.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO |
$4.32
|
| Rate for Payer: United Healthcare HMO Rider |
$4.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.34
|
| Rate for Payer: Vantage Medical Group Senior |
$7.34
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$5.88
|
| Rate for Payer: Blue Shield of California EPN |
$3.84
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$6.09
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.71
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.47
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$6.09
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.85
|
| Rate for Payer: InnovAge PACE Commercial |
$3.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.33
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
| Rate for Payer: Riverside University Health System MISP |
$3.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.81
|
| Rate for Payer: United Healthcare All Other HMO |
$3.81
|
| Rate for Payer: United Healthcare HMO Rider |
$3.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$1.08
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| 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
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.77 |
| 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 |
$1.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$1.08
|
| 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: 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: InnovAge PACE Commercial |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| 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 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 49884-364-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.41 |
| 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 |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.87
|
| 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: 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: InnovAge PACE Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| 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 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 49884-364-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.87
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| 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 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$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: Anthem Blue Cross of CA Exchange |
$40.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.33
|
| Rate for Payer: Blue Shield of California Commercial |
$51.32
|
| Rate for Payer: Blue Shield of California EPN |
$33.52
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: Cigna of CA HMO |
$53.76
|
| Rate for Payer: Cigna of CA PPO |
$62.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: InnovAge PACE Commercial |
$42.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$54.60
|
| 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 |
$42.00
|
| Rate for Payer: United Healthcare All Other HMO |
$42.00
|
| Rate for Payer: United Healthcare HMO Rider |
$42.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Blue Shield of California Commercial |
$64.93
|
| Rate for Payer: Blue Shield of California EPN |
$42.34
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$54.60
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.07
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| 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
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 49884-362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| 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 |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.43
|
| 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: 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: InnovAge PACE Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| 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 49884-362-01
|
| 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 |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.43
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| 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
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.53
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| 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
|
|
