|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 6936716604
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Distinction Transplant |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 904759160
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| 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: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$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: 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
|
| 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
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 5789670301
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| 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: 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: 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
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 5789670301
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| 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: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| 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: 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
|
| 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
|
$0.06
|
|
|
Service Code
|
NDC 574060801
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| 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: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$0.01
|
| 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
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 904759160
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$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: 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: 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
|
$0.01
|
|
|
Service Code
|
NDC 904759160
|
| Hospital Charge Code |
ERX3074
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$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: 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: 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
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 904759160
|
| Hospital Charge Code |
ERX3074
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| 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: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$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: 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
|
| 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
|
$15.06
|
|
|
Service Code
|
NDC 0069-0242-30
|
| Hospital Charge Code |
1712468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: Blue Shield of California Commercial |
$10.72
|
| Rate for Payer: Blue Shield of California EPN |
$7.71
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Cigna of CA HMO |
$10.54
|
| Rate for Payer: Cigna of CA PPO |
$10.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: Galaxy Health WC |
$12.80
|
| Rate for Payer: Global Benefits Group Commercial |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.61
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: Networks By Design Commercial |
$9.79
|
| Rate for Payer: Prime Health Services Commercial |
$12.80
|
|
|
FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]
|
Facility
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 0069-0242-30
|
| Hospital Charge Code |
1712468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.97
|
| Rate for Payer: Blue Distinction Transplant |
$9.04
|
| Rate for Payer: Blue Shield of California Commercial |
$11.10
|
| Rate for Payer: Blue Shield of California EPN |
$8.80
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Cigna of CA HMO |
$10.54
|
| Rate for Payer: Cigna of CA PPO |
$10.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.80
|
| Rate for Payer: Dignity Health Media |
$12.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.02
|
| Rate for Payer: Galaxy Health WC |
$12.80
|
| Rate for Payer: Global Benefits Group Commercial |
$9.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.61
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: Networks By Design Commercial |
$9.79
|
| Rate for Payer: Prime Health Services Commercial |
$12.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.53
|
| Rate for Payer: United Healthcare All Other HMO |
$7.53
|
| Rate for Payer: United Healthcare HMO Rider |
$7.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.80
|
| Rate for Payer: Vantage Medical Group Senior |
$12.80
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$12,158.84
|
|
|
Service Code
|
APR-DRG 7223
|
| Min. Negotiated Rate |
$9,327.11 |
| Max. Negotiated Rate |
$12,158.84 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,327.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,158.84
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$17,649.48
|
|
|
Service Code
|
APR-DRG 7224
|
| Min. Negotiated Rate |
$13,539.01 |
| Max. Negotiated Rate |
$17,649.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,539.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,649.48
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$8,922.29
|
|
|
Service Code
|
APR-DRG 7222
|
| Min. Negotiated Rate |
$6,844.33 |
| Max. Negotiated Rate |
$8,922.29 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,844.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,922.29
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$5,946.41
|
|
|
Service Code
|
APR-DRG 7221
|
| Min. Negotiated Rate |
$4,561.52 |
| Max. Negotiated Rate |
$5,946.41 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,561.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,946.41
|
|
|
FEXOFENADINE 180 MG TABLET [25425]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 41167-4120-3
|
| Hospital Charge Code |
1711887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| 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: 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: 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 |
1711887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| 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 |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Distinction Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| 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 Media |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.52
|
| 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: 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
|
| 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
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
OP
|
$281.93
|
|
|
Service Code
|
NDC 52015-080-01
|
| Hospital Charge Code |
1712567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.66 |
| Max. Negotiated Rate |
$239.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$184.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$239.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$155.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$155.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$167.97
|
| Rate for Payer: Blue Distinction Transplant |
$169.16
|
| Rate for Payer: Blue Shield of California Commercial |
$207.78
|
| Rate for Payer: Blue Shield of California EPN |
$164.65
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cigna of CA HMO |
$197.35
|
| Rate for Payer: Cigna of CA PPO |
$197.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.64
|
| Rate for Payer: Dignity Health Media |
$239.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$112.77
|
| Rate for Payer: Galaxy Health WC |
$239.64
|
| Rate for Payer: Global Benefits Group Commercial |
$169.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$211.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.66
|
| Rate for Payer: Multiplan Commercial |
$225.54
|
| Rate for Payer: Networks By Design Commercial |
$183.25
|
| Rate for Payer: Prime Health Services Commercial |
$239.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$169.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$169.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$140.96
|
| Rate for Payer: United Healthcare All Other HMO |
$140.96
|
| Rate for Payer: United Healthcare HMO Rider |
$140.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$140.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$239.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.64
|
| Rate for Payer: Vantage Medical Group Senior |
$239.64
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
IP
|
$281.93
|
|
|
Service Code
|
NDC 52015-080-01
|
| Hospital Charge Code |
1712567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.66 |
| Max. Negotiated Rate |
$239.64 |
| Rate for Payer: Blue Shield of California Commercial |
$200.73
|
| Rate for Payer: Blue Shield of California EPN |
$144.35
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cigna of CA HMO |
$197.35
|
| Rate for Payer: Cigna of CA PPO |
$197.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.77
|
| Rate for Payer: Galaxy Health WC |
$239.64
|
| Rate for Payer: Global Benefits Group Commercial |
$169.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.66
|
| Rate for Payer: Multiplan Commercial |
$225.54
|
| Rate for Payer: Networks By Design Commercial |
$183.25
|
| Rate for Payer: Prime Health Services Commercial |
$239.64
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
OP
|
$41.46
|
|
|
Service Code
|
NDC 52015-700-23
|
| Hospital Charge Code |
NDG229582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.70
|
| Rate for Payer: Blue Distinction Transplant |
$24.88
|
| Rate for Payer: Blue Shield of California Commercial |
$30.56
|
| Rate for Payer: Blue Shield of California EPN |
$24.21
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cigna of CA HMO |
$29.02
|
| Rate for Payer: Cigna of CA PPO |
$29.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.24
|
| Rate for Payer: Dignity Health Media |
$35.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.58
|
| Rate for Payer: Galaxy Health WC |
$35.24
|
| Rate for Payer: Global Benefits Group Commercial |
$24.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$31.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Multiplan Commercial |
$33.17
|
| Rate for Payer: Networks By Design Commercial |
$26.95
|
| Rate for Payer: Prime Health Services Commercial |
$35.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$24.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$24.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.73
|
| Rate for Payer: United Healthcare All Other HMO |
$20.73
|
| Rate for Payer: United Healthcare HMO Rider |
$20.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.24
|
| Rate for Payer: Vantage Medical Group Senior |
$35.24
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$41.46
|
|
|
Service Code
|
NDC 52015-700-23
|
| Hospital Charge Code |
NDG229582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Blue Shield of California Commercial |
$29.52
|
| Rate for Payer: Blue Shield of California EPN |
$21.23
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cigna of CA HMO |
$29.02
|
| Rate for Payer: Cigna of CA PPO |
$29.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.58
|
| Rate for Payer: Galaxy Health WC |
$35.24
|
| Rate for Payer: Global Benefits Group Commercial |
$24.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Multiplan Commercial |
$33.17
|
| Rate for Payer: Networks By Design Commercial |
$26.95
|
| Rate for Payer: Prime Health Services Commercial |
$35.24
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
OP
|
$41.46
|
|
|
Service Code
|
NDC 52015-700-22
|
| Hospital Charge Code |
NDG229582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.70
|
| Rate for Payer: Blue Distinction Transplant |
$24.88
|
| Rate for Payer: Blue Shield of California Commercial |
$30.56
|
| Rate for Payer: Blue Shield of California EPN |
$24.21
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cigna of CA HMO |
$29.02
|
| Rate for Payer: Cigna of CA PPO |
$29.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.24
|
| Rate for Payer: Dignity Health Media |
$35.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.58
|
| Rate for Payer: Galaxy Health WC |
$35.24
|
| Rate for Payer: Global Benefits Group Commercial |
$24.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$31.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Multiplan Commercial |
$33.17
|
| Rate for Payer: Networks By Design Commercial |
$26.95
|
| Rate for Payer: Prime Health Services Commercial |
$35.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$24.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$24.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.73
|
| Rate for Payer: United Healthcare All Other HMO |
$20.73
|
| Rate for Payer: United Healthcare HMO Rider |
$20.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.24
|
| Rate for Payer: Vantage Medical Group Senior |
$35.24
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$41.46
|
|
|
Service Code
|
NDC 52015-700-22
|
| Hospital Charge Code |
NDG229582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Blue Shield of California Commercial |
$29.52
|
| Rate for Payer: Blue Shield of California EPN |
$21.23
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cigna of CA HMO |
$29.02
|
| Rate for Payer: Cigna of CA PPO |
$29.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.58
|
| Rate for Payer: Galaxy Health WC |
$35.24
|
| Rate for Payer: Global Benefits Group Commercial |
$24.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Multiplan Commercial |
$33.17
|
| Rate for Payer: Networks By Design Commercial |
$26.95
|
| Rate for Payer: Prime Health Services Commercial |
$35.24
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
OP
|
$658.47
|
|
|
Service Code
|
NDC 61314-318-10
|
| Hospital Charge Code |
NDG211102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.03 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$431.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$559.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$362.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$362.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$392.32
|
| Rate for Payer: Blue Distinction Transplant |
$395.08
|
| Rate for Payer: Blue Shield of California Commercial |
$485.29
|
| Rate for Payer: Blue Shield of California EPN |
$384.55
|
| 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 |
$559.70
|
| Rate for Payer: Dignity Health Media |
$559.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$559.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$263.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$493.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$439.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$250.88
|
| 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: 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 |
$329.24
|
| Rate for Payer: United Healthcare All Other HMO |
$329.24
|
| Rate for Payer: United Healthcare HMO Rider |
$329.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$329.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$559.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$559.70
|
| Rate for Payer: Vantage Medical Group Senior |
$559.70
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
OP
|
$658.47
|
|
|
Service Code
|
NDC 61314-318-01
|
| Hospital Charge Code |
NDG211102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.03 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$431.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$559.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$362.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$362.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$392.32
|
| Rate for Payer: Blue Distinction Transplant |
$395.08
|
| Rate for Payer: Blue Shield of California Commercial |
$485.29
|
| Rate for Payer: Blue Shield of California EPN |
$384.55
|
| 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 |
$559.70
|
| Rate for Payer: Dignity Health Media |
$559.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$559.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$263.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$493.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$439.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$250.88
|
| 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: 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 |
$329.24
|
| Rate for Payer: United Healthcare All Other HMO |
$329.24
|
| Rate for Payer: United Healthcare HMO Rider |
$329.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$329.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$559.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$559.70
|
| Rate for Payer: Vantage Medical Group Senior |
$559.70
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
IP
|
$658.47
|
|
|
Service Code
|
NDC 61314-318-10
|
| Hospital Charge Code |
NDG211102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.03 |
| Max. Negotiated Rate |
$559.70 |
| Rate for Payer: Blue Shield of California Commercial |
$468.83
|
| Rate for Payer: Blue Shield of California EPN |
$337.14
|
| 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: EPIC Health Plan Commercial |
$263.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$263.39
|
| Rate for Payer: Galaxy Health WC |
$559.70
|
| Rate for Payer: Global Benefits Group Commercial |
$395.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$439.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$250.88
|
| 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 |
$248.64
|
| Rate for Payer: United Healthcare All Other HMO |
$242.84
|
| Rate for Payer: United Healthcare HMO Rider |
$237.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.30
|
|
