|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
|
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
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
$0.97
|
|
|
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
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 50 MG CAPSULE [9719]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 0527-3220-37
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: BCBS Transplant Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.95
|
| Rate for Payer: IEHP medi-cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: Riverside University Health MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
IP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 50 MG CAPSULE [9719]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
OP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| Hospital Charge Code |
1710025
|
|
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 50 MG CAPSULE [9719]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: BCBS Transplant Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.95
|
| Rate for Payer: IEHP medi-cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: Riverside University Health MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 0527-3220-37
|
| Hospital Charge Code |
1710025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| Hospital Charge Code |
1715985
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: IEHP medi-cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: Riverside University Health MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| Hospital Charge Code |
1715985
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
OP
|
$22.61
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
ERX204693
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.36
|
| Rate for Payer: BCBS Transplant Transplant |
$13.57
|
| Rate for Payer: Blue Shield of California Commercial |
$14.22
|
| Rate for Payer: Blue Shield of California EPN |
$11.06
|
| Rate for Payer: Cash Price |
$10.17
|
| Rate for Payer: Central Health Plan Commercial |
$18.09
|
| Rate for Payer: Cigna of CA HMO |
$15.83
|
| Rate for Payer: Cigna of CA PPO |
$15.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.04
|
| Rate for Payer: Galaxy Health WC |
$19.22
|
| Rate for Payer: Global Benefits Group Commercial |
$13.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.96
|
| Rate for Payer: IEHP medi-cal |
$7.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.52
|
| Rate for Payer: Multiplan Commercial |
$16.96
|
| Rate for Payer: Networks By Design Commercial |
$14.70
|
| Rate for Payer: Prime Health Services Commercial |
$19.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.57
|
| Rate for Payer: Riverside University Health MISP |
$9.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.30
|
| Rate for Payer: United Healthcare All Other HMO |
$11.30
|
| Rate for Payer: United Healthcare HMO Rider |
$11.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.22
|
| Rate for Payer: Vantage Medical Group Senior |
$19.22
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
IP
|
$22.61
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
ERX204693
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$16.96
|
| Rate for Payer: Blue Shield of California EPN |
$12.07
|
| Rate for Payer: Cash Price |
$10.17
|
| Rate for Payer: Cash Price |
$10.17
|
| Rate for Payer: Central Health Plan Commercial |
$18.09
|
| Rate for Payer: Cigna of CA HMO |
$15.83
|
| Rate for Payer: Cigna of CA PPO |
$15.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.04
|
| Rate for Payer: Galaxy Health WC |
$19.22
|
| Rate for Payer: Global Benefits Group Commercial |
$13.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.52
|
| Rate for Payer: Multiplan Commercial |
$16.96
|
| Rate for Payer: Networks By Design Commercial |
$14.70
|
| Rate for Payer: Prime Health Services Commercial |
$19.22
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
IP
|
$1.45
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
1711546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
OP
|
$1.45
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
1711546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: BCBS Transplant Transplant |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.09
|
| Rate for Payer: IEHP medi-cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: Riverside University Health MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
OP
|
$1.18
|
|
|
Service Code
|
NDC 69543-150-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: BCBS Transplant Transplant |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Central Health Plan Commercial |
$0.94
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.47
|
| Rate for Payer: Galaxy Health WC |
$1.00
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.89
|
| Rate for Payer: IEHP medi-cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.00
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: Riverside University Health MISP |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.59
|
| Rate for Payer: United Healthcare All Other HMO |
$0.59
|
| Rate for Payer: United Healthcare HMO Rider |
$0.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1.00
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
IP
|
$2.37
|
|
|
Service Code
|
NDC 13925-504-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Central Health Plan Commercial |
$1.90
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
IP
|
$2.74
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Central Health Plan Commercial |
$2.19
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: Networks By Design Commercial |
$1.78
|
| Rate for Payer: Prime Health Services Commercial |
$2.33
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
IP
|
$1.18
|
|
|
Service Code
|
NDC 69543-150-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Central Health Plan Commercial |
$0.94
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Galaxy Health WC |
$1.00
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.00
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
OP
|
$2.74
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
1711606
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.62
|
| Rate for Payer: BCBS Transplant Transplant |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Central Health Plan Commercial |
$2.19
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.06
|
| Rate for Payer: IEHP medi-cal |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: Networks By Design Commercial |
$1.78
|
| Rate for Payer: Prime Health Services Commercial |
$2.33
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.64
|
| Rate for Payer: Riverside University Health MISP |
$1.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.37
|
| Rate for Payer: United Healthcare All Other HMO |
$1.37
|
| Rate for Payer: United Healthcare HMO Rider |
$1.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.33
|
| Rate for Payer: Vantage Medical Group Senior |
$2.33
|
|
