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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

OP

$0.24

Service Code	NDC L4084-048-15
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-20
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

OP

$0.24

Service Code	NDC L4084-048-08
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-30
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

OP

$0.24

Service Code	NDC L4084-048-10
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-55
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-25
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-15
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-10
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-40
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

IP

$0.24

Service Code	NDC L4084-048-35
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]

Facility

IP

$0.26

Service Code	NDC 63323-820-01
Hospital Charge Code	NDG215468
Hospital Revenue Code	258
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]

Facility

OP

$0.26

Service Code	NDC 63323-820-01
Hospital Charge Code	NDG215468
Hospital Revenue Code	258
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]

Facility

IP

$0.26

Service Code	NDC 63323-820-00
Hospital Charge Code	NDG215468
Hospital Revenue Code	258
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]

Facility

OP

$0.26

Service Code	NDC 63323-820-00
Hospital Charge Code	NDG215468
Hospital Revenue Code	258
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

FEBUXOSTAT 40 MG TABLET [97133]

Facility

OP

$3.04

Service Code	NDC 72205-028-30
Hospital Charge Code	1712494
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.82
Rate for Payer: Aetna of CA Government/Medicare	$1.82
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.28

FEBUXOSTAT 40 MG TABLET [97133]

Facility

OP

$3.00

Service Code	NDC 60687-538-21
Hospital Charge Code	1712494
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

FEBUXOSTAT 40 MG TABLET [97133]

Facility

IP

$3.04

Service Code	NDC 72205-028-30
Hospital Charge Code	1712494
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cigna of CA HMO/PPO	$2.43
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.28

FEBUXOSTAT 40 MG TABLET [97133]

Facility

IP

$3.00

Service Code	NDC 60687-538-21
Hospital Charge Code	1712494
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

FEBUXOSTAT 40 MG TABLET [97133]

Facility

OP

$3.00

Service Code	NDC 60687-538-11
Hospital Charge Code	1712494
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

FEBUXOSTAT 40 MG TABLET [97133]

Facility

IP

$3.00

Service Code	NDC 60687-538-11
Hospital Charge Code	1712494
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

FEBUXOSTAT 80 MG TABLET [97134]

Facility

OP

$13.20

Service Code	NDC 64764-677-30
Hospital Charge Code	1712495
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$5.94
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.90

FEBUXOSTAT 80 MG TABLET [97134]

Facility

IP

$13.20

Service Code	NDC 64764-677-30
Hospital Charge Code	1712495
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of CA HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.90

FEDRATINIB 100 MG CAPSULE [225695]

Facility

OP

$249.16

Service Code	NDC 59572-720-12
Hospital Revenue Code	636
Min. Negotiated Rate	$137.04
Max. Negotiated Rate	$186.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$149.50
Rate for Payer: Aetna of CA Government/Medicare	$149.50
Rate for Payer: Cash Price	$112.12
Rate for Payer: Health Smart Auto/Commercial	$149.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$149.50
Rate for Payer: LLUH Dept of Risk Management WC	$137.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$186.87

FEDRATINIB 100 MG CAPSULE [225695]

Facility

IP

$249.16

Service Code	NDC 59572-720-12
Hospital Revenue Code	636
Min. Negotiated Rate	$137.04
Max. Negotiated Rate	$199.33
Rate for Payer: Cash Price	$112.12
Rate for Payer: Cigna of CA HMO/PPO	$199.33
Rate for Payer: Health Smart Auto/Commercial	$149.50
Rate for Payer: LLUH Dept of Risk Management WC	$137.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$186.87

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