|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
OP
|
$188.88
|
|
|
Service Code
|
NDC 6050548332
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.78 |
| Max. Negotiated Rate |
$160.55 |
| Rate for Payer: Adventist Health Commercial |
$37.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$123.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$160.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$141.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.20
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cigna of CA HMO |
$132.22
|
| Rate for Payer: Cigna of CA PPO |
$132.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$160.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$160.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$160.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$132.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.55
|
| Rate for Payer: EPIC Health Plan Senior |
$75.55
|
| Rate for Payer: Galaxy Health WC |
$160.55
|
| Rate for Payer: Global Benefits Group Commercial |
$113.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$119.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$68.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$111.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$132.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.22
|
| Rate for Payer: Multiplan Commercial |
$151.10
|
| Rate for Payer: Networks By Design Commercial |
$122.77
|
| Rate for Payer: Prime Health Services Commercial |
$160.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$113.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$113.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$94.44
|
| Rate for Payer: United Healthcare All Other HMO |
$94.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$94.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$160.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$160.55
|
| Rate for Payer: Vantage Medical Group Senior |
$160.55
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
OP
|
$269.83
|
|
|
Service Code
|
NDC 0480259634
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$229.36 |
| Rate for Payer: Adventist Health Commercial |
$53.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$176.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$229.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$202.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.15
|
| Rate for Payer: Cash Price |
$121.42
|
| Rate for Payer: Cigna of CA HMO |
$188.88
|
| Rate for Payer: Cigna of CA PPO |
$188.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$229.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$229.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$229.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$188.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.93
|
| Rate for Payer: EPIC Health Plan Senior |
$107.93
|
| Rate for Payer: Galaxy Health WC |
$229.36
|
| Rate for Payer: Global Benefits Group Commercial |
$161.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$171.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$159.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$188.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$188.88
|
| Rate for Payer: Multiplan Commercial |
$215.86
|
| Rate for Payer: Networks By Design Commercial |
$175.39
|
| Rate for Payer: Prime Health Services Commercial |
$229.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$161.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$161.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.91
|
| Rate for Payer: United Healthcare All Other HMO |
$134.91
|
| Rate for Payer: United Healthcare HMO Rider |
$134.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$229.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$229.36
|
| Rate for Payer: Vantage Medical Group Senior |
$229.36
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
IP
|
$269.83
|
|
|
Service Code
|
NDC 0480259634
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$229.36 |
| Rate for Payer: Adventist Health Commercial |
$53.97
|
| Rate for Payer: Blue Shield of California Commercial |
$136.80
|
| Rate for Payer: Blue Shield of California Commercial |
$207.50
|
| Rate for Payer: Cash Price |
$121.42
|
| Rate for Payer: Cigna of CA HMO |
$188.88
|
| Rate for Payer: Cigna of CA PPO |
$188.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$188.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.93
|
| Rate for Payer: EPIC Health Plan Senior |
$107.93
|
| Rate for Payer: Galaxy Health WC |
$229.36
|
| Rate for Payer: Global Benefits Group Commercial |
$161.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$171.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$159.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.76
|
| Rate for Payer: Multiplan Commercial |
$215.86
|
| Rate for Payer: Networks By Design Commercial |
$175.39
|
| Rate for Payer: Prime Health Services Commercial |
$229.36
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
OP
|
$312.30
|
|
|
Service Code
|
NDC 5201508001
|
| 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 |
$200.40
|
| Rate for Payer: Cash Price |
$140.54
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$198.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.26
|
| 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 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$45.93
|
|
|
Service Code
|
NDC 5201570022
|
| 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 |
$23.29
|
| Rate for Payer: Blue Shield of California Commercial |
$35.32
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$32.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.10
|
| 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 5201570023
|
| 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 |
$29.47
|
| Rate for Payer: Cash Price |
$20.67
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.10
|
| 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
|
OP
|
$45.93
|
|
|
Service Code
|
NDC 5201570022
|
| 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 |
$29.47
|
| Rate for Payer: Cash Price |
$20.67
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.10
|
| 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 5201570023
|
| 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 |
$23.29
|
| Rate for Payer: Blue Shield of California Commercial |
$35.32
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Cigna of CA HMO |
$32.15
|
| Rate for Payer: Cigna of CA PPO |
$32.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.10
|
| 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
|
|
|
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 |
$0.31 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cash Price |
$171.72
|
| 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 |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$324.36
|
| Rate for Payer: Global Benefits Group Commercial |
$228.96
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$0.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$242.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| 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 |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
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 |
$193.47
|
| Rate for Payer: Blue Shield of California Commercial |
$293.45
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cigna of CA HMO |
$267.12
|
| Rate for Payer: Cigna of CA PPO |
$267.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$242.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$225.14
|
| 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 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [233797]
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cash Price |
$171.72
|
| 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 |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$324.36
|
| Rate for Payer: Global Benefits Group Commercial |
$228.96
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$0.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$242.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| 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 |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [233797]
|
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 |
$193.47
|
| Rate for Payer: Blue Shield of California Commercial |
$293.45
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cigna of CA HMO |
$267.12
|
| Rate for Payer: Cigna of CA PPO |
$267.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$242.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$225.14
|
| 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-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
IP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.69 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Blue Shield of California Commercial |
$333.84
|
| Rate for Payer: Blue Shield of California Commercial |
$506.36
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO |
$460.93
|
| Rate for Payer: Cigna of CA PPO |
$460.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$460.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.39
|
| Rate for Payer: EPIC Health Plan Senior |
$263.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$418.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$388.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.03
|
| Rate for Payer: Multiplan Commercial |
$526.78
|
| Rate for Payer: Networks By Design Commercial |
$329.24
|
| Rate for Payer: Prime Health Services Commercial |
$559.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$247.12
|
| Rate for Payer: United Healthcare All Other HMO |
$240.54
|
| Rate for Payer: United Healthcare HMO Rider |
$235.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.65
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
OP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO |
$460.93
|
| Rate for Payer: Cigna of CA PPO |
$460.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$460.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$0.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$418.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$526.78
|
| Rate for Payer: Networks By Design Commercial |
$329.24
|
| Rate for Payer: Prime Health Services Commercial |
$559.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$395.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$395.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$247.12
|
| Rate for Payer: United Healthcare All Other HMO |
$240.54
|
| Rate for Payer: United Healthcare HMO Rider |
$235.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.65
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [211101]
|
Facility
|
IP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.69 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Blue Shield of California Commercial |
$333.84
|
| Rate for Payer: Blue Shield of California Commercial |
$506.36
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO |
$460.93
|
| Rate for Payer: Cigna of CA PPO |
$460.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$460.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.39
|
| Rate for Payer: EPIC Health Plan Senior |
$263.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$418.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$388.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.03
|
| Rate for Payer: Multiplan Commercial |
$526.78
|
| Rate for Payer: Networks By Design Commercial |
$329.24
|
| Rate for Payer: Prime Health Services Commercial |
$559.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$247.12
|
| Rate for Payer: United Healthcare All Other HMO |
$240.54
|
| Rate for Payer: United Healthcare HMO Rider |
$235.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.65
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [211101]
|
Facility
|
OP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO |
$460.93
|
| Rate for Payer: Cigna of CA PPO |
$460.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$460.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$0.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$418.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$526.78
|
| Rate for Payer: Networks By Design Commercial |
$329.24
|
| Rate for Payer: Prime Health Services Commercial |
$559.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$395.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$395.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$247.12
|
| Rate for Payer: United Healthcare All Other HMO |
$240.54
|
| Rate for Payer: United Healthcare HMO Rider |
$235.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.65
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$11.99 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.99
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
|
|
FINASTERIDE (PROSCAR) CRUSHED TABLET IN WATER [4081461]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$11.99 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.93
|
| 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 |
$11.99
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
FINASTERIDE (PROSCAR) CRUSHED TABLET IN WATER [4081461]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
FINERENONE 10 MG TABLET [232074]
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
NDC 5041954001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.37
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$20.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.45
|
| Rate for Payer: EPIC Health Plan Senior |
$11.45
|
| Rate for Payer: Galaxy Health WC |
$24.33
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.03
|
| Rate for Payer: Multiplan Commercial |
$22.90
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.31
|
| Rate for Payer: United Healthcare All Other HMO |
$14.31
|
| Rate for Payer: United Healthcare HMO Rider |
$14.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.33
|
| Rate for Payer: Vantage Medical Group Senior |
$24.33
|
|
|
FINERENONE 10 MG TABLET [232074]
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
NDC 5041954001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California Commercial |
$14.51
|
| Rate for Payer: Blue Shield of California Commercial |
$22.01
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$20.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.45
|
| Rate for Payer: EPIC Health Plan Senior |
$11.45
|
| Rate for Payer: Galaxy Health WC |
$24.33
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$22.90
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.33
|
|
|
FINERENONE 20 MG TABLET [232075]
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
NDC 5041954101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California Commercial |
$14.51
|
| Rate for Payer: Blue Shield of California Commercial |
$22.01
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$20.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.45
|
| Rate for Payer: EPIC Health Plan Senior |
$11.45
|
| Rate for Payer: Galaxy Health WC |
$24.33
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$22.90
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.33
|
|
|
FINERENONE 20 MG TABLET [232075]
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
NDC 5041954101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.37
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$20.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.45
|
| Rate for Payer: EPIC Health Plan Senior |
$11.45
|
| Rate for Payer: Galaxy Health WC |
$24.33
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.03
|
| Rate for Payer: Multiplan Commercial |
$22.90
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.31
|
| Rate for Payer: United Healthcare All Other HMO |
$14.31
|
| Rate for Payer: United Healthcare HMO Rider |
$14.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.33
|
| Rate for Payer: Vantage Medical Group Senior |
$24.33
|
|
|
FLAVORX LIQUID [100560]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 7857300074
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
