|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 49884-362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Senior |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Senior |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.66
|
| 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
|
$0.78
|
|
|
Service Code
|
NDC 49884-362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 49884-363-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| 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 |
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 |
$0.86
|
| 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 50 MG CAPSULE [9719]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 0115-4422-01
|
| 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 |
$0.86
|
| 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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| 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 |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
OP
|
$23.99
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$20.39 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.99
|
| Rate for Payer: Blue Shield of California Commercial |
$14.63
|
| Rate for Payer: Blue Shield of California EPN |
$11.71
|
| Rate for Payer: Cash Price |
$13.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.39
|
| Rate for Payer: Dignity Health Senior |
$20.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.85
|
| Rate for Payer: Heritage Provider Network Senior |
$14.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.79
|
| Rate for Payer: Multiplan Commercial |
$17.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.39
|
| Rate for Payer: Vantage Medical Group Senior |
$20.39
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
IP
|
$15.14
|
|
|
Service Code
|
NDC 66993-457-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.25
|
| Rate for Payer: Heritage Provider Network Senior |
$10.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
IP
|
$23.99
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$17.99 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Cash Price |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.24
|
| Rate for Payer: Heritage Provider Network Senior |
$16.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$17.99
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]
|
Facility
|
OP
|
$15.14
|
|
|
Service Code
|
NDC 66993-457-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$12.87 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.36
|
| Rate for Payer: Blue Shield of California Commercial |
$9.24
|
| Rate for Payer: Blue Shield of California EPN |
$7.39
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.87
|
| Rate for Payer: Dignity Health Senior |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.37
|
| Rate for Payer: Heritage Provider Network Senior |
$9.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.60
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.06
|
| Rate for Payer: TriValley Medical Group Senior |
$6.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.87
|
| Rate for Payer: Vantage Medical Group Senior |
$12.87
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 64980-566-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.58
|
| Rate for Payer: Dignity Health Senior |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.58
|
| Rate for Payer: Vantage Medical Group Senior |
$1.58
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: Dignity Health Senior |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 64980-566-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
DAPSONE 25 MG TABLET [2132]
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.33
|
| Rate for Payer: Dignity Health Senior |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Senior |
$1.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.33
|
| Rate for Payer: Vantage Medical Group Senior |
$2.33
|
|
|
DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]
|
Facility
|
OP
|
$2.37
|
|
|
Service Code
|
NDC 9994-0802-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.01
|
| Rate for Payer: Dignity Health Senior |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Vantage Medical Group Senior |
$2.01
|
|
|
DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]
|
Facility
|
IP
|
$2.37
|
|
|
Service Code
|
NDC 9994-0802-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$16.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.73
|
|
