|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527136901
|
| 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 Non-Gatekeeper |
$4.70
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$3.81
|
| 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 |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$3.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527136906
|
| 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: Aetna of CA Non-Gatekeeper |
$5.56
|
| 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 Foundation Hospitals 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
|
$8.64
|
|
|
Service Code
|
NDC 0527136906
|
| 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 Non-Gatekeeper |
$5.34
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$4.32
|
| 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 |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.58
|
|
|
Service Code
|
NDC 4988436401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.02
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.19
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115443301
|
| 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 Non-Gatekeeper |
$1.22
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.99
|
| 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 |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$1.58
|
|
|
Service Code
|
NDC 4988436401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| 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 |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.19
|
| 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 |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115443301
|
| 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: Aetna of CA Non-Gatekeeper |
$1.27
|
| 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 Foundation Hospitals 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
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.10
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Kaiser Foundation Hospitals 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: United Healthcare All Other HMO/non HMO |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.91
|
| 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 |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$40.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
| 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
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
IP
|
$4,215.86
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$763.07 |
| Max. Negotiated Rate |
$3,161.89 |
| Rate for Payer: Adventist Health Commercial |
$843.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,715.01
|
| Rate for Payer: Cash Price |
$1,897.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,939.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,276.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,951.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1,951.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$763.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,053.96
|
| Rate for Payer: Multiplan Commercial |
$3,161.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,523.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,395.87
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
|
OP
|
$4,215.86
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$763.07 |
| Max. Negotiated Rate |
$3,583.48 |
| Rate for Payer: Adventist Health Commercial |
$843.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,605.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,583.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,318.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,161.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,108.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2,571.67
|
| Rate for Payer: Blue Shield of California EPN |
$2,057.34
|
| Rate for Payer: Cash Price |
$1,897.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,939.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,583.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,583.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,583.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,698.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,951.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1,951.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,010.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$763.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,053.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,951.10
|
| Rate for Payer: Multiplan Commercial |
$3,161.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,686.34
|
| Rate for Payer: TriValley Medical Group Senior |
$1,686.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,523.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,395.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,583.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,583.48
|
| Rate for Payer: Vantage Medical Group Senior |
$3,583.48
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115441101
|
| 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: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Cash Price |
$0.44
|
| 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 Foundation Hospitals 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
|
$0.97
|
|
|
Service Code
|
NDC 0115441101
|
| 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 Non-Gatekeeper |
$0.60
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.49
|
| 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 |
$0.44
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.78
|
|
|
Service Code
|
NDC 4988436201
|
| 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 Non-Gatekeeper |
$0.48
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| 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 |
$0.35
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 4988436201
|
| 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: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Cash Price |
$0.35
|
| 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 Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 6808430021
|
| 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 Non-Gatekeeper |
$1.21
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| 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 |
$0.88
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$1.95
|
|
|
Service Code
|
NDC 6808430021
|
| 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: Aetna of CA Non-Gatekeeper |
$1.26
|
| Rate for Payer: Cash Price |
$0.88
|
| 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 Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
|
|
DANTROLENE 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 4988436301
|
| 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: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 Foundation Hospitals 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 4988436301
|
| 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 Non-Gatekeeper |
$0.78
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
| 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 |
$0.57
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 0115442201
|
| 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 Non-Gatekeeper |
$0.97
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| 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 |
$0.71
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 50 MG CAPSULE [9719]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 0115442201
|
| 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: Aetna of CA Non-Gatekeeper |
$1.01
|
| 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 Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
|
|
DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994080262
|
| 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: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 Foundation Hospitals 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 9994080262
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.09
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
OP
|
$15.11
|
|
|
Service Code
|
NDC 0310621039
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$12.84 |
| Rate for Payer: Adventist Health Commercial |
$3.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.56
|
| Rate for Payer: Blue Shield of California Commercial |
$9.22
|
| Rate for Payer: Blue Shield of California EPN |
$7.37
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.35
|
| Rate for Payer: Heritage Provider Network Senior |
$9.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.58
|
| Rate for Payer: Multiplan Commercial |
$11.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.04
|
| Rate for Payer: TriValley Medical Group Senior |
$6.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.84
|
| Rate for Payer: Vantage Medical Group Senior |
$12.84
|
|
|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
OP
|
$15.14
|
|
|
Service Code
|
NDC 6699345730
|
| 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 Non-Gatekeeper |
$9.36
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$7.57
|
| 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 |
$6.81
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$7.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
