|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
ERX222940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$560.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$378.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$342.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$342.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$301.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$367.77
|
| Rate for Payer: BCBS Transplant Transplant |
$373.49
|
| Rate for Payer: Blue Shield of California Commercial |
$391.55
|
| Rate for Payer: Blue Shield of California EPN |
$304.40
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Central Health Plan Commercial |
$497.99
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$560.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$466.87
|
| Rate for Payer: IEHP medi-cal |
$217.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: Riverside University Health MISP |
$249.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$373.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$311.24
|
| Rate for Payer: United Healthcare All Other HMO |
$311.24
|
| Rate for Payer: United Healthcare HMO Rider |
$311.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
IP
|
$622.49
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
ERX222940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$560.24 |
| Rate for Payer: Blue Shield of California Commercial |
$466.87
|
| Rate for Payer: Blue Shield of California EPN |
$332.41
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Central Health Plan Commercial |
$497.99
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$560.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
|
|
Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity)
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 68720
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,183.44 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,830.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,246.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,313.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,830.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$4,830.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,246.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,521.57
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,830.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,830.79
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,922.50
|
| Rate for Payer: IEHP medi-cal |
$7,970.80
|
| Rate for Payer: IEHP Medicare Advantage |
$4,830.79
|
| Rate for Payer: Innovage PACE Commercial |
$7,246.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,830.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,473.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,473.26
|
| Rate for Payer: Prime Health Services Medicare |
$5,120.64
|
| Rate for Payer: Riverside University Health MISP |
$5,313.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,313.87
|
| Rate for Payer: Vantage Medical Group Senior |
$4,830.79
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
OP
|
$885.00
|
|
|
Service Code
|
CPT J9120
|
| Hospital Charge Code |
1755120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$1,996.43 |
| Rate for Payer: Adventist Health Medi-Cal |
$668.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,317.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$836.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$735.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$735.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.40
|
| Rate for Payer: BCBS Transplant Transplant |
$531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,996.43
|
| Rate for Payer: Blue Shield of California EPN |
$1,814.94
|
| Rate for Payer: Caremore Medicare Advantage |
$668.90
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cash Price |
$398.25
|
| 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 |
$1,003.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$903.02
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$668.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$668.90
|
| 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: Health Plan of Nevada - Sierra Transplant Other |
$663.75
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,097.00
|
| Rate for Payer: IEHP medi-cal |
$1,103.69
|
| Rate for Payer: IEHP Medicare Advantage |
$668.90
|
| Rate for Payer: Innovage PACE Commercial |
$1,003.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$668.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$896.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$896.33
|
| 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: Prime Health Services Medicare |
$709.04
|
| Rate for Payer: Riverside University Health MISP |
$735.79
|
| 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 |
$442.50
|
| Rate for Payer: United Healthcare All Other HMO |
$442.50
|
| Rate for Payer: United Healthcare HMO Rider |
$442.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$442.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,003.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$735.79
|
| Rate for Payer: Vantage Medical Group Senior |
$668.90
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
IP
|
$885.00
|
|
|
Service Code
|
CPT J9120
|
| Hospital Charge Code |
1755120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.00 |
| Max. Negotiated Rate |
$796.50 |
| Rate for Payer: Blue Shield of California Commercial |
$663.75
|
| Rate for Payer: Blue Shield of California EPN |
$472.59
|
| Rate for Payer: Cash Price |
$398.25
|
| 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 Transplant |
$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 |
$590.30
|
| 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
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
OP
|
$2,072.77
|
|
|
Service Code
|
CPT J0875
|
| Hospital Charge Code |
ERX206124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$1,865.49 |
| Rate for Payer: Adventist Health Medi-Cal |
$15.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$94.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$29.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.30
|
| Rate for Payer: BCBS Transplant Transplant |
$1,243.66
|
| Rate for Payer: Blue Shield of California Commercial |
$20.87
|
| Rate for Payer: Blue Shield of California EPN |
$18.97
|
| Rate for Payer: Caremore Medicare Advantage |
$15.29
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Central Health Plan Commercial |
$1,658.22
|
| Rate for Payer: Cigna of CA HMO |
$1,450.94
|
| Rate for Payer: Cigna of CA PPO |
$1,450.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.65
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$15.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.29
|
| Rate for Payer: Galaxy Health WC |
$1,761.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,243.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,865.49
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,554.58
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$25.08
|
| Rate for Payer: IEHP medi-cal |
$25.23
|
| Rate for Payer: IEHP Medicare Advantage |
$15.29
|
| Rate for Payer: Innovage PACE Commercial |
$22.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,382.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$414.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.49
|
| Rate for Payer: Multiplan Commercial |
$1,554.58
|
| Rate for Payer: Networks By Design Commercial |
$1,036.38
|
| Rate for Payer: Prime Health Services Commercial |
$1,761.85
|
| Rate for Payer: Prime Health Services Medicare |
$16.21
|
| Rate for Payer: Riverside University Health MISP |
$16.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,243.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,243.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,036.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1,036.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1,036.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,036.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.82
|
| Rate for Payer: Vantage Medical Group Senior |
$15.29
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
IP
|
$2,072.77
|
|
|
Service Code
|
CPT J0875
|
| Hospital Charge Code |
ERX206124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$414.55 |
| Max. Negotiated Rate |
$1,865.49 |
| Rate for Payer: Blue Shield of California Commercial |
$1,554.58
|
| Rate for Payer: Blue Shield of California EPN |
$1,106.86
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Central Health Plan Commercial |
$1,658.22
|
| Rate for Payer: Cigna of CA HMO |
$1,450.94
|
| Rate for Payer: Cigna of CA PPO |
$1,450.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$829.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$829.11
|
| Rate for Payer: Galaxy Health WC |
$1,761.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,243.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,865.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,382.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$414.55
|
| Rate for Payer: Multiplan Commercial |
$1,554.58
|
| Rate for Payer: Networks By Design Commercial |
$1,036.38
|
| Rate for Payer: Prime Health Services Commercial |
$1,761.85
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.50
|
| Rate for Payer: BCBS Transplant Transplant |
$4.57
|
| Rate for Payer: Blue Shield of California Commercial |
$4.79
|
| Rate for Payer: Blue Shield of California EPN |
$3.72
|
| Rate for Payer: Cash Price |
$3.42
|
| 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: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$5.71
|
| Rate for Payer: IEHP medi-cal |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: Riverside University Health 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 |
$3.80
|
| Rate for Payer: United Healthcare All Other HMO |
$3.80
|
| Rate for Payer: United Healthcare HMO Rider |
$3.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Blue Shield of California Commercial |
$6.48
|
| Rate for Payer: Blue Shield of California EPN |
$4.61
|
| Rate for Payer: Cash Price |
$3.89
|
| 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: 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: 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
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Blue Shield of California Commercial |
$5.71
|
| Rate for Payer: Blue Shield of California EPN |
$4.06
|
| Rate for Payer: Cash Price |
$3.42
|
| 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: 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: 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
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.10
|
| Rate for Payer: BCBS Transplant Transplant |
$5.18
|
| Rate for Payer: Blue Shield of California Commercial |
$5.43
|
| Rate for Payer: Blue Shield of California EPN |
$4.22
|
| Rate for Payer: Cash Price |
$3.89
|
| 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: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$6.48
|
| Rate for Payer: IEHP medi-cal |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.18
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$7.34
|
| Rate for Payer: Vantage Medical Group Senior |
$7.34
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
OP
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.93
|
| Rate for Payer: BCBS Transplant Transplant |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| 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: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.41
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.18
|
| Rate for Payer: IEHP medi-cal |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| 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: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| 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 |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.08
|
| 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: BCBS Transplant Transplant |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| 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: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$1.48
|
| Rate for Payer: IEHP medi-cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
IP
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| 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: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| 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 |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$51.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$46.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$40.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.63
|
| Rate for Payer: BCBS Transplant Transplant |
$50.40
|
| Rate for Payer: Blue Shield of California Commercial |
$52.84
|
| Rate for Payer: Blue Shield of California EPN |
$41.08
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| 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: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$63.00
|
| Rate for Payer: IEHP medi-cal |
$29.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| 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
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
IP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Blue Shield of California Commercial |
$63.00
|
| Rate for Payer: Blue Shield of California EPN |
$44.86
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| 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 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
OP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$750.42 |
| Max. Negotiated Rate |
$3,376.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,278.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,189.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,063.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,063.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,816.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,216.74
|
| Rate for Payer: BCBS Transplant Transplant |
$2,251.26
|
| Rate for Payer: Blue Shield of California Commercial |
$2,360.07
|
| Rate for Payer: Blue Shield of California EPN |
$1,834.78
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Central Health Plan Commercial |
$3,001.68
|
| Rate for Payer: Cigna of CA HMO |
$2,626.47
|
| Rate for Payer: Cigna of CA PPO |
$2,626.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,189.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,500.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,500.84
|
| Rate for Payer: Galaxy Health WC |
$3,189.28
|
| Rate for Payer: Global Benefits Group Commercial |
$2,251.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,376.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,814.08
|
| Rate for Payer: IEHP medi-cal |
$1,313.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,502.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$750.42
|
| Rate for Payer: Multiplan Commercial |
$2,814.08
|
| Rate for Payer: Networks By Design Commercial |
$1,876.05
|
| Rate for Payer: Prime Health Services Commercial |
$3,189.28
|
| Rate for Payer: Riverside University Health MISP |
$1,500.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,251.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,251.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,876.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1,876.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1,876.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,876.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,189.28
|
| Rate for Payer: Vantage Medical Group Senior |
$3,189.28
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
IP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$750.42 |
| Max. Negotiated Rate |
$3,376.89 |
| Rate for Payer: Blue Shield of California Commercial |
$2,814.08
|
| Rate for Payer: Blue Shield of California EPN |
$2,003.62
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Central Health Plan Commercial |
$3,001.68
|
| Rate for Payer: Cigna of CA HMO |
$2,626.47
|
| Rate for Payer: Cigna of CA PPO |
$2,626.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,500.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,500.84
|
| Rate for Payer: Galaxy Health WC |
$3,189.28
|
| Rate for Payer: Global Benefits Group Commercial |
$2,251.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,376.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,502.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$750.42
|
| Rate for Payer: Multiplan Commercial |
$2,814.08
|
| Rate for Payer: Networks By Design Commercial |
$1,876.05
|
| Rate for Payer: Prime Health Services Commercial |
$3,189.28
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| 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: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| 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
IP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| 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: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| 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
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.43
|
| 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: BCBS Transplant Transplant |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| 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: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.59
|
| Rate for Payer: IEHP medi-cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.57
|
| Rate for Payer: BCBS Transplant Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| 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: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.87
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.73
|
| Rate for Payer: IEHP medi-cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
OP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.15
|
| Rate for Payer: BCBS Transplant Transplant |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| 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: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.46
|
| Rate for Payer: IEHP medi-cal |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.30
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.17
|
| Rate for Payer: Riverside University Health 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 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 68084-300-21
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| 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: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.30
|
| 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
|
|
