|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 2055502101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 5789670310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0574060801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 2055502101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 5789670301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904759080
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904759080
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]
|
Facility
|
IP
|
$11.60
|
|
|
Service Code
|
NDC 0069-0242-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$9.86 |
| Rate for Payer: Adventist Health Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California Commercial |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$5.64
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna of CA HMO |
$8.12
|
| Rate for Payer: Cigna of CA PPO |
$8.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.64
|
| Rate for Payer: EPIC Health Plan Senior |
$4.64
|
| Rate for Payer: Galaxy Health WC |
$9.86
|
| Rate for Payer: Global Benefits Group Commercial |
$6.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$9.28
|
| Rate for Payer: Networks By Design Commercial |
$7.54
|
| Rate for Payer: Prime Health Services Commercial |
$9.86
|
|
|
FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]
|
Facility
|
OP
|
$11.60
|
|
|
Service Code
|
NDC 0069-0242-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$9.86 |
| Rate for Payer: Adventist Health Commercial |
$2.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.12
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna of CA HMO |
$8.12
|
| Rate for Payer: Cigna of CA PPO |
$8.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.64
|
| Rate for Payer: EPIC Health Plan Senior |
$4.64
|
| Rate for Payer: Galaxy Health WC |
$9.86
|
| Rate for Payer: Global Benefits Group Commercial |
$6.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.12
|
| Rate for Payer: Multiplan Commercial |
$9.28
|
| Rate for Payer: Networks By Design Commercial |
$7.54
|
| Rate for Payer: Prime Health Services Commercial |
$9.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.80
|
| Rate for Payer: United Healthcare All Other HMO |
$5.80
|
| Rate for Payer: United Healthcare HMO Rider |
$5.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.86
|
| Rate for Payer: Vantage Medical Group Senior |
$9.86
|
|
|
FEXOFENADINE 180 MG TABLET [25425]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 41167-4120-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
FEXOFENADINE 180 MG TABLET [25425]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 41167-4120-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
FIBRINOGEN-THROMBIN 9.5 CM X 4.8 CM TOPICAL PATCH [105430]
|
Facility
|
IP
|
$843.79
|
|
|
Service Code
|
NDC 0338-8701-00
|
| Min. Negotiated Rate |
$168.76 |
| Max. Negotiated Rate |
$717.22 |
| Rate for Payer: Adventist Health Commercial |
$168.76
|
| Rate for Payer: Cash Price |
$464.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$337.52
|
| Rate for Payer: EPIC Health Plan Senior |
$337.52
|
| Rate for Payer: Galaxy Health WC |
$717.22
|
| Rate for Payer: Global Benefits Group Commercial |
$506.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$562.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$321.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$522.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.51
|
| Rate for Payer: Multiplan Commercial |
$675.03
|
| Rate for Payer: Networks By Design Commercial |
$548.46
|
| Rate for Payer: Prime Health Services Commercial |
$717.22
|
|
|
FIBRINOGEN-THROMBIN 9.5 CM X 4.8 CM TOPICAL PATCH [105430]
|
Facility
|
OP
|
$843.79
|
|
|
Service Code
|
NDC 0338-8701-00
|
| Min. Negotiated Rate |
$168.76 |
| Max. Negotiated Rate |
$717.22 |
| Rate for Payer: Adventist Health Commercial |
$168.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$553.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$717.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$464.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$632.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$518.17
|
| Rate for Payer: Cash Price |
$464.09
|
| Rate for Payer: Cigna of CA HMO |
$540.03
|
| Rate for Payer: Cigna of CA PPO |
$624.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$717.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$717.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$717.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$337.52
|
| Rate for Payer: EPIC Health Plan Senior |
$337.52
|
| Rate for Payer: Galaxy Health WC |
$717.22
|
| Rate for Payer: Global Benefits Group Commercial |
$506.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$562.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$321.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$522.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$590.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$590.65
|
| Rate for Payer: Multiplan Commercial |
$675.03
|
| Rate for Payer: Networks By Design Commercial |
$548.46
|
| Rate for Payer: Prime Health Services Commercial |
$717.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$506.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$506.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.89
|
| Rate for Payer: United Healthcare All Other HMO |
$421.89
|
| Rate for Payer: United Healthcare HMO Rider |
$421.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$421.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$717.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$717.22
|
| Rate for Payer: Vantage Medical Group Senior |
$717.22
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
OP
|
$312.30
|
|
|
Service Code
|
NDC 52015-080-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.46 |
| Max. Negotiated Rate |
$265.45 |
| Rate for Payer: Adventist Health Commercial |
$62.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$204.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$265.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$171.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$234.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$191.78
|
| Rate for Payer: Cash Price |
$171.77
|
| Rate for Payer: Cigna of CA HMO |
$218.61
|
| Rate for Payer: Cigna of CA PPO |
$218.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$265.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$265.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$265.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$124.92
|
| Rate for Payer: EPIC Health Plan Senior |
$124.92
|
| Rate for Payer: Galaxy Health WC |
$265.45
|
| Rate for Payer: Global Benefits Group Commercial |
$187.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$208.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$118.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$193.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$74.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$218.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$218.61
|
| Rate for Payer: Multiplan Commercial |
$249.84
|
| Rate for Payer: Networks By Design Commercial |
$203.00
|
| Rate for Payer: Prime Health Services Commercial |
$265.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$187.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$187.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$156.15
|
| Rate for Payer: United Healthcare All Other HMO |
$156.15
|
| Rate for Payer: United Healthcare HMO Rider |
$156.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$156.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$265.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$265.45
|
| Rate for Payer: Vantage Medical Group Senior |
$265.45
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
IP
|
$312.30
|
|
|
Service Code
|
NDC 52015-080-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.46 |
| Max. Negotiated Rate |
$265.45 |
| Rate for Payer: Adventist Health Commercial |
$62.46
|
| Rate for Payer: Blue Shield of California Commercial |
$230.48
|
| Rate for Payer: Blue Shield of California EPN |
$151.78
|
| Rate for Payer: Cash Price |
$171.77
|
| Rate for Payer: Cigna of CA HMO |
$218.61
|
| Rate for Payer: Cigna of CA PPO |
$218.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$124.92
|
| Rate for Payer: EPIC Health Plan Senior |
$124.92
|
| Rate for Payer: Galaxy Health WC |
$265.45
|
| Rate for Payer: Global Benefits Group Commercial |
$187.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$208.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$118.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$193.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$74.95
|
| Rate for Payer: Multiplan Commercial |
$249.84
|
| Rate for Payer: Networks By Design Commercial |
$203.00
|
| Rate for Payer: Prime Health Services Commercial |
$265.45
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$45.93
|
|
|
Service Code
|
NDC 52015-700-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Blue Shield of California Commercial |
$33.90
|
| Rate for Payer: Blue Shield of California EPN |
$22.32
|
| Rate for Payer: Cash Price |
$25.26
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$32.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.37
|
| Rate for Payer: EPIC Health Plan Senior |
$18.37
|
| Rate for Payer: Galaxy Health WC |
$39.04
|
| Rate for Payer: Global Benefits Group Commercial |
$27.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.02
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Networks By Design Commercial |
$29.85
|
| Rate for Payer: Prime Health Services Commercial |
$39.04
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
OP
|
$45.93
|
|
|
Service Code
|
NDC 52015-700-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.21
|
| Rate for Payer: Cash Price |
$25.26
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$32.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.37
|
| Rate for Payer: EPIC Health Plan Senior |
$18.37
|
| Rate for Payer: Galaxy Health WC |
$39.04
|
| Rate for Payer: Global Benefits Group Commercial |
$27.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.15
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Networks By Design Commercial |
$29.85
|
| Rate for Payer: Prime Health Services Commercial |
$39.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.96
|
| Rate for Payer: United Healthcare All Other HMO |
$22.96
|
| Rate for Payer: United Healthcare HMO Rider |
$22.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.04
|
| Rate for Payer: Vantage Medical Group Senior |
$39.04
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$45.93
|
|
|
Service Code
|
NDC 52015-700-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Blue Shield of California Commercial |
$33.90
|
| Rate for Payer: Blue Shield of California EPN |
$22.32
|
| Rate for Payer: Cash Price |
$25.26
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$32.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.37
|
| Rate for Payer: EPIC Health Plan Senior |
$18.37
|
| Rate for Payer: Galaxy Health WC |
$39.04
|
| Rate for Payer: Global Benefits Group Commercial |
$27.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.02
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Networks By Design Commercial |
$29.85
|
| Rate for Payer: Prime Health Services Commercial |
$39.04
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
OP
|
$45.93
|
|
|
Service Code
|
NDC 52015-700-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Networks By Design Commercial |
$29.85
|
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.21
|
| Rate for Payer: Cash Price |
$25.26
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$32.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.37
|
| Rate for Payer: EPIC Health Plan Senior |
$18.37
|
| Rate for Payer: Galaxy Health WC |
$39.04
|
| Rate for Payer: Global Benefits Group Commercial |
$27.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.15
|
| Rate for Payer: Prime Health Services Commercial |
$39.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.96
|
| Rate for Payer: United Healthcare All Other HMO |
$22.96
|
| Rate for Payer: United Healthcare HMO Rider |
$22.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.04
|
| Rate for Payer: Vantage Medical Group Senior |
$39.04
|
|
|
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [233796]
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.32 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Blue Shield of California Commercial |
$281.62
|
| Rate for Payer: Blue Shield of California EPN |
$185.46
|
| Rate for Payer: Cash Price |
$209.88
|
| Rate for Payer: Cigna of CA HMO |
$267.12
|
| Rate for Payer: Cigna of CA PPO |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.64
|
| Rate for Payer: EPIC Health Plan Senior |
$152.64
|
| Rate for Payer: Galaxy Health WC |
$324.36
|
| Rate for Payer: Global Benefits Group Commercial |
$228.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$145.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$236.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$305.28
|
| Rate for Payer: Networks By Design Commercial |
$190.80
|
| Rate for Payer: Prime Health Services Commercial |
$324.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.21
|
| Rate for Payer: United Healthcare All Other HMO |
$139.40
|
| Rate for Payer: United Healthcare HMO Rider |
$136.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$124.97
|
|
|
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [233796]
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$250.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$209.88
|
| Rate for Payer: Cash Price |
$209.88
|
| Rate for Payer: Cigna of CA HMO |
$267.12
|
| Rate for Payer: Cigna of CA PPO |
$267.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: EPIC Health Plan Senior |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$324.36
|
| Rate for Payer: Global Benefits Group Commercial |
$228.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$305.28
|
| Rate for Payer: Networks By Design Commercial |
$190.80
|
| Rate for Payer: Prime Health Services Commercial |
$324.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$228.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$228.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.21
|
| Rate for Payer: United Healthcare All Other HMO |
$139.40
|
| Rate for Payer: United Healthcare HMO Rider |
$136.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$124.97
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
