|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Blue Shield of California Commercial |
$8.77
|
| Rate for Payer: Blue Shield of California EPN |
$7.01
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Senior |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.90
|
| Rate for Payer: Heritage Provider Network Senior |
$8.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.75
|
| Rate for Payer: TriValley Medical Group Senior |
$5.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$10.78 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.73
|
| Rate for Payer: Heritage Provider Network Senior |
$9.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Blue Shield of California Commercial |
$8.77
|
| Rate for Payer: Blue Shield of California EPN |
$7.01
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Senior |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.90
|
| Rate for Payer: Heritage Provider Network Senior |
$8.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.75
|
| Rate for Payer: TriValley Medical Group Senior |
$5.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
OP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$15.54 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.54
|
| Rate for Payer: Blue Shield of California Commercial |
$6.12
|
| Rate for Payer: Blue Shield of California EPN |
$6.12
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.64
|
| Rate for Payer: Dignity Health Senior |
$12.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.88
|
| Rate for Payer: Heritage Provider Network Senior |
$6.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.41
|
| Rate for Payer: Multiplan Commercial |
$11.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.95
|
| Rate for Payer: TriValley Medical Group Senior |
$5.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.64
|
| Rate for Payer: Vantage Medical Group Senior |
$12.64
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
IP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$11.15 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.88
|
| Rate for Payer: Heritage Provider Network Senior |
$6.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$11.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.92
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
IP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$7.92
|
| 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 |
$6.67
|
| Rate for Payer: Heritage Provider Network Senior |
$6.67
|
| 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 |
$5.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.77
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
|
OP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$15.54 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.54
|
| Rate for Payer: Blue Shield of California Commercial |
$6.12
|
| Rate for Payer: Blue Shield of California EPN |
$6.12
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cash Price |
$7.92
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.87
|
| 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: Molina Healthcare of CA Medi-Cal |
$10.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.76
|
| Rate for Payer: TriValley Medical Group Senior |
$5.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.53 |
| Max. Negotiated Rate |
$495.30 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$356.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$447.09
|
| Rate for Payer: Heritage Provider Network Senior |
$447.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.10
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.53 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$352.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$453.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Blue Shield of California Commercial |
$402.84
|
| Rate for Payer: Blue Shield of California EPN |
$322.28
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$429.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Senior |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$422.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$408.79
|
| Rate for Payer: Heritage Provider Network Senior |
$408.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$315.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$264.16
|
| Rate for Payer: TriValley Medical Group Senior |
$264.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$330.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.53 |
| Max. Negotiated Rate |
$495.30 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$356.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$447.09
|
| Rate for Payer: Heritage Provider Network Senior |
$447.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.10
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.53 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$352.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$453.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Blue Shield of California Commercial |
$402.84
|
| Rate for Payer: Blue Shield of California EPN |
$322.28
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$429.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Senior |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$422.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$408.79
|
| Rate for Payer: Heritage Provider Network Senior |
$408.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$315.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$264.16
|
| Rate for Payer: TriValley Medical Group Senior |
$264.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$330.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
IP
|
$660.40
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.53 |
| Max. Negotiated Rate |
$495.30 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$356.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$447.09
|
| Rate for Payer: Heritage Provider Network Senior |
$447.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.10
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
|
OP
|
$660.40
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.53 |
| Max. Negotiated Rate |
$561.34 |
| Rate for Payer: Adventist Health Commercial |
$132.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$352.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$453.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.30
|
| Rate for Payer: Blue Shield of California Commercial |
$402.84
|
| Rate for Payer: Blue Shield of California EPN |
$322.28
|
| Rate for Payer: Cash Price |
$363.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$429.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.34
|
| Rate for Payer: Dignity Health Senior |
$561.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$422.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$408.79
|
| Rate for Payer: Heritage Provider Network Senior |
$408.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$315.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.28
|
| Rate for Payer: Multiplan Commercial |
$495.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$264.16
|
| Rate for Payer: TriValley Medical Group Senior |
$264.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$330.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$330.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$561.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.34
|
| Rate for Payer: Vantage Medical Group Senior |
$561.34
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
IP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.19 |
| Max. Negotiated Rate |
$663.75 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Cash Price |
$486.75
|
| 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 |
$409.75
|
| Rate for Payer: Heritage Provider Network Senior |
$409.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.19
|
| 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 |
$319.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$293.02
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
|
OP
|
$885.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.19 |
| Max. Negotiated Rate |
$1,910.10 |
| Rate for Payer: Adventist Health Commercial |
$177.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$473.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$608.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$454.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$333.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$333.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,910.10
|
| Rate for Payer: Blue Shield of California Commercial |
$752.25
|
| Rate for Payer: Blue Shield of California EPN |
$752.25
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Cash Price |
$486.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$407.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$333.22
|
| Rate for Payer: Dignity Health Senior |
$333.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$566.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$302.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$409.75
|
| Rate for Payer: Heritage Provider Network Senior |
$409.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$288.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$302.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$422.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$348.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$381.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$381.68
|
| Rate for Payer: Multiplan Commercial |
$663.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$354.00
|
| Rate for Payer: TriValley Medical Group Senior |
$354.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$319.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$293.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$333.22
|
| Rate for Payer: Vantage Medical Group Senior |
$333.22
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$4.19
|
| 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 |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.27
|
| Rate for Payer: Blue Shield of California EPN |
$4.22
|
| Rate for Payer: Cash Price |
$4.75
|
| 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 |
$4.12
|
| 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: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.46
|
| Rate for Payer: TriValley Medical Group Senior |
$3.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.34
|
| Rate for Payer: Vantage Medical Group Senior |
$7.34
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$4.75
|
| 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
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.71
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$4.19
|
| 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 |
$3.63
|
| 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: Molina Healthcare of CA Medi-Cal |
$5.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.33
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.04
|
| Rate for Payer: TriValley Medical Group Senior |
$3.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$1.08
|
| 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 |
$0.94
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 49884-364-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.87
|
| 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
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 49884-364-01
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.87
|
| 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 |
$0.75
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.63
|
| Rate for Payer: TriValley Medical Group Senior |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$1.08
|
| 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 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.87
|
| Rate for Payer: Heritage Provider Network Senior |
$56.87
|
| 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
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$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: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Blue Shield of California Commercial |
$51.24
|
| Rate for Payer: Blue Shield of California EPN |
$40.99
|
| Rate for Payer: Cash Price |
$46.20
|
| 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 |
$40.07
|
| 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: Molina Healthcare of CA Medi-Cal |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.60
|
| Rate for Payer: TriValley Medical Group Senior |
$33.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
