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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

OP

$0.02

Service Code	NDC 5789670301
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

OP

$0.01

Service Code	NDC 904759160
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

IP

$0.02

Service Code	NDC 2055502101
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

IP

$0.30

Service Code	NDC 6936716604
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

OP

$0.23

Service Code	NDC 6936716620
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
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	$0.10
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	$0.17

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

IP

$0.02

Service Code	NDC 5789670301
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

IP

$0.23

Service Code	NDC 6936716620
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
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	$0.17

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

OP

$0.30

Service Code	NDC 6936716604
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]

Facility

OP

$0.01

Service Code	NDC 5789670310
Hospital Charge Code	1710172
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]

Facility

IP

$0.01

Service Code	NDC 904759160
Hospital Charge Code	ERX3074
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]

Facility

OP

$0.01

Service Code	NDC 904759160
Hospital Charge Code	ERX3074
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]

Facility

IP

$15.06

Service Code	NDC 0069-0242-30
Hospital Charge Code	1712468
Hospital Revenue Code	259
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$12.05
Rate for Payer: Cash Price	$6.78
Rate for Payer: Cigna of CA HMO/PPO	$12.05
Rate for Payer: Health Smart Auto/Commercial	$9.04
Rate for Payer: LLUH Dept of Risk Management WC	$8.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.30

FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]

Facility

OP

$15.06

Service Code	NDC 0069-0242-30
Hospital Charge Code	1712468
Hospital Revenue Code	259
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$11.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.04
Rate for Payer: Aetna of CA Government/Medicare	$9.04
Rate for Payer: Cash Price	$6.78
Rate for Payer: Health Smart Auto/Commercial	$9.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.04
Rate for Payer: LLUH Dept of Risk Management WC	$8.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.30

FEXOFENADINE 180 MG TABLET [25425]

Facility

OP

$0.69

Service Code	NDC 41167-4120-3
Hospital Charge Code	1711887
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

FEXOFENADINE 180 MG TABLET [25425]

Facility

IP

$0.69

Service Code	NDC 41167-4120-3
Hospital Charge Code	1711887
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

FIDAXOMICIN 200 MG TABLET [153338]

Facility

OP

$281.93

Service Code	NDC 52015-080-01
Hospital Charge Code	1712567
Hospital Revenue Code	259
Min. Negotiated Rate	$155.06
Max. Negotiated Rate	$211.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$169.16
Rate for Payer: Aetna of CA Government/Medicare	$169.16
Rate for Payer: Cash Price	$126.87
Rate for Payer: Health Smart Auto/Commercial	$169.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$169.16
Rate for Payer: LLUH Dept of Risk Management WC	$155.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$211.45

FIDAXOMICIN 200 MG TABLET [153338]

Facility

IP

$281.93

Service Code	NDC 52015-080-01
Hospital Charge Code	1712567
Hospital Revenue Code	259
Min. Negotiated Rate	$155.06
Max. Negotiated Rate	$225.54
Rate for Payer: Cash Price	$126.87
Rate for Payer: Cigna of CA HMO/PPO	$225.54
Rate for Payer: Health Smart Auto/Commercial	$169.16
Rate for Payer: LLUH Dept of Risk Management WC	$155.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$211.45

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

OP

$41.46

Service Code	NDC 52015-700-22
Hospital Charge Code	NDG229582
Hospital Revenue Code	259
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$31.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.88
Rate for Payer: Aetna of CA Government/Medicare	$24.88
Rate for Payer: Cash Price	$18.66
Rate for Payer: Health Smart Auto/Commercial	$24.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.88
Rate for Payer: LLUH Dept of Risk Management WC	$22.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.10

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

OP

$41.46

Service Code	NDC 52015-700-23
Hospital Charge Code	NDG229582
Hospital Revenue Code	259
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$31.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.88
Rate for Payer: Aetna of CA Government/Medicare	$24.88
Rate for Payer: Cash Price	$18.66
Rate for Payer: Health Smart Auto/Commercial	$24.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.88
Rate for Payer: LLUH Dept of Risk Management WC	$22.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.10

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

IP

$41.46

Service Code	NDC 52015-700-22
Hospital Charge Code	NDG229582
Hospital Revenue Code	259
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$33.17
Rate for Payer: Cash Price	$18.66
Rate for Payer: Cigna of CA HMO/PPO	$33.17
Rate for Payer: Health Smart Auto/Commercial	$24.88
Rate for Payer: LLUH Dept of Risk Management WC	$22.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.10

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

IP

$41.46

Service Code	NDC 52015-700-23
Hospital Charge Code	NDG229582
Hospital Revenue Code	259
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$33.17
Rate for Payer: Cash Price	$18.66
Rate for Payer: Cigna of CA HMO/PPO	$33.17
Rate for Payer: Health Smart Auto/Commercial	$24.88
Rate for Payer: LLUH Dept of Risk Management WC	$22.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.10

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]

Facility

IP

$658.47

Service Code	NDC 61314-318-01
Hospital Charge Code	NDG211102
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$526.78
Rate for Payer: Cash Price	$296.31
Rate for Payer: Cigna of CA HMO/PPO	$526.78
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$493.85

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]

Facility

IP

$658.47

Service Code	NDC 61314-318-10
Hospital Charge Code	NDG211102
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$526.78
Rate for Payer: Cash Price	$296.31
Rate for Payer: Cigna of CA HMO/PPO	$526.78
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$493.85

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]

Facility

OP

$658.47

Service Code	NDC 61314-318-10
Hospital Charge Code	NDG211102
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$493.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$395.08
Rate for Payer: Aetna of CA Government/Medicare	$395.08
Rate for Payer: Cash Price	$296.31
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$493.85

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]

Facility

OP

$658.47

Service Code	NDC 61314-318-01
Hospital Charge Code	NDG211102
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$493.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$395.08
Rate for Payer: Aetna of CA Government/Medicare	$395.08
Rate for Payer: Cash Price	$296.31
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$493.85

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