|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
1712462
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
IP
|
$13.04
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1720153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.36
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
OP
|
$13.04
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1720153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$27.43 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.43
|
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$7.46
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.08
|
| Rate for Payer: Dignity Health Senior |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.04
|
| Rate for Payer: Heritage Provider Network Senior |
$6.04
|
| Rate for Payer: IEHP Medi-Cal |
$12.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
OP
|
$14.40
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1755114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$27.43 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.43
|
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$7.46
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.24
|
| Rate for Payer: Dignity Health Senior |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.67
|
| Rate for Payer: Heritage Provider Network Senior |
$6.67
|
| Rate for Payer: IEHP Medi-Cal |
$12.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
IP
|
$14.40
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1755114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.89
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.75
|
| Rate for Payer: Heritage Provider Network Senior |
$9.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.81
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
ERX222938
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.67 |
| Max. Negotiated Rate |
$529.12 |
| Rate for Payer: Adventist Health Commercial |
$124.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$332.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$427.65
|
| 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 |
$466.87
|
| Rate for Payer: Blue Shield of California Commercial |
$386.57
|
| Rate for Payer: Blue Shield of California EPN |
$365.40
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$404.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$529.12
|
| Rate for Payer: Dignity Health Senior |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$385.32
|
| Rate for Payer: Heritage Provider Network Senior |
$385.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$300.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.62
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
IP
|
$622.49
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
ERX222938
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.67 |
| Max. Negotiated Rate |
$466.87 |
| Rate for Payer: Adventist Health Commercial |
$124.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$427.65
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$421.43
|
| Rate for Payer: Heritage Provider Network Senior |
$421.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.62
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
ERX222939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.67 |
| Max. Negotiated Rate |
$529.12 |
| Rate for Payer: Adventist Health Commercial |
$124.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$332.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$427.65
|
| 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 |
$466.87
|
| Rate for Payer: Blue Shield of California Commercial |
$386.57
|
| Rate for Payer: Blue Shield of California EPN |
$365.40
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$404.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$529.12
|
| Rate for Payer: Dignity Health Senior |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$385.32
|
| Rate for Payer: Heritage Provider Network Senior |
$385.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$300.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.62
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
IP
|
$622.49
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
ERX222939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.67 |
| Max. Negotiated Rate |
$466.87 |
| Rate for Payer: Adventist Health Commercial |
$124.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$427.65
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$421.43
|
| Rate for Payer: Heritage Provider Network Senior |
$421.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.62
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
|
|
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 |
$112.67 |
| Max. Negotiated Rate |
$529.12 |
| Rate for Payer: Adventist Health Commercial |
$124.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$332.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$427.65
|
| 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 |
$466.87
|
| Rate for Payer: Blue Shield of California Commercial |
$386.57
|
| Rate for Payer: Blue Shield of California EPN |
$365.40
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$404.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$529.12
|
| Rate for Payer: Dignity Health Senior |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$385.32
|
| Rate for Payer: Heritage Provider Network Senior |
$385.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$300.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.62
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| 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 |
$112.67 |
| Max. Negotiated Rate |
$466.87 |
| Rate for Payer: Adventist Health Commercial |
$124.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$427.65
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$421.43
|
| Rate for Payer: Heritage Provider Network Senior |
$421.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.62
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
|
|
Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity)
|
Facility
OP
|
$9,178.50
|
|
|
Service Code
|
CPT 68720
|
| Min. Negotiated Rate |
$816.58 |
| Max. Negotiated Rate |
$9,178.50 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| 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 HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,313.87
|
| Rate for Payer: Dignity Health Senior |
$4,830.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,830.79
|
| Rate for Payer: Humana Medicare |
$4,830.79
|
| Rate for Payer: IEHP Medi-Cal |
$816.58
|
| Rate for Payer: IEHP Medicare Advantage |
$4,830.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,178.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,700.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,086.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,086.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,313.87
|
| Rate for Payer: TriValley Medical Group Senior |
$4,830.79
|
| 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 |
$26.04 |
| Max. Negotiated Rate |
$1,519.76 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,317.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$608.00
|
| 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 HMO/PPO |
$26.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1,519.76
|
| Rate for Payer: Blue Shield of California EPN |
$1,519.76
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$407.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,003.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$735.79
|
| Rate for Payer: Dignity Health Senior |
$735.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$566.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$668.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$409.76
|
| Rate for Payer: Heritage Provider Network Senior |
$409.76
|
| Rate for Payer: Humana Medicare |
$668.90
|
| Rate for Payer: IEHP Medi-Cal |
$1,050.44
|
| Rate for Payer: IEHP Medicare Advantage |
$668.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,270.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$789.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$842.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$842.82
|
| Rate for Payer: Multiplan Commercial |
$663.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$735.79
|
| Rate for Payer: TriValley Medical Group Senior |
$668.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$322.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$295.68
|
| 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 |
$160.18 |
| Max. Negotiated Rate |
$663.75 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$608.00
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$407.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$477.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$599.14
|
| Rate for Payer: Heritage Provider Network Senior |
$599.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.25
|
| Rate for Payer: Multiplan Commercial |
$663.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$322.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$295.68
|
|
|
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 |
$1,554.58 |
| Rate for Payer: Adventist Health Commercial |
$414.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,423.99
|
| 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 HMO/PPO |
$31.86
|
| Rate for Payer: Blue Shield of California Commercial |
$17.10
|
| Rate for Payer: Blue Shield of California EPN |
$17.10
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$953.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.82
|
| Rate for Payer: Dignity Health Senior |
$16.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,326.57
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$959.69
|
| Rate for Payer: Heritage Provider Network Senior |
$959.69
|
| Rate for Payer: Humana Medicare |
$15.29
|
| Rate for Payer: IEHP Medi-Cal |
$30.81
|
| Rate for Payer: IEHP Medicare Advantage |
$15.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$375.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$518.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.27
|
| Rate for Payer: Multiplan Commercial |
$1,554.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.82
|
| Rate for Payer: TriValley Medical Group Senior |
$15.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$755.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$692.51
|
| 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 |
$375.17 |
| Max. Negotiated Rate |
$1,554.58 |
| Rate for Payer: Adventist Health Commercial |
$414.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,423.99
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$953.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,119.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,403.27
|
| Rate for Payer: Heritage Provider Network Senior |
$1,403.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$375.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$518.19
|
| Rate for Payer: Multiplan Commercial |
$1,554.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$755.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$692.51
|
|
|
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 |
$1.56 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Adventist Health Commercial |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.94
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.85
|
| Rate for Payer: Heritage Provider Network Senior |
$5.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
|
|
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 |
$1.38 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.23
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.15
|
| Rate for Payer: Heritage Provider Network Senior |
$5.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
|
|
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 |
$1.56 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: Adventist Health Commercial |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.94
|
| 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 |
$6.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.37
|
| Rate for Payer: Blue Shield of California EPN |
$5.07
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.34
|
| Rate for Payer: Dignity Health Senior |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.35
|
| Rate for Payer: Heritage Provider Network Senior |
$5.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
| 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
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.23
|
| 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 |
$5.71
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.47
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: Dignity Health Senior |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.71
|
| Rate for Payer: Heritage Provider Network Senior |
$4.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| 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
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.08
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
|
|
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 |
$0.36 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
|
|
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 |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.08
|
| 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 |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Senior |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| 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
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| 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 |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: Dignity Health Senior |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.71
|
| 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 |
$63.00
|
| Rate for Payer: Blue Shield of California Commercial |
$52.16
|
| Rate for Payer: Blue Shield of California EPN |
$49.31
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Senior |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.00
|
| Rate for Payer: Heritage Provider Network Senior |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
