|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 63323-820-00
|
| Hospital Charge Code |
NDG215468
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 63323-820-01
|
| Hospital Charge Code |
NDG215468
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 63323-820-01
|
| Hospital Charge Code |
NDG215468
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687-538-11
|
| Hospital Charge Code |
1712494
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687-538-21
|
| Hospital Charge Code |
1712494
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687-538-21
|
| Hospital Charge Code |
1712494
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687-538-11
|
| Hospital Charge Code |
1712494
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
NDC 72205-028-30
|
| Hospital Charge Code |
1712494
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
NDC 72205-028-30
|
| Hospital Charge Code |
1712494
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
|
|
FEBUXOSTAT 80 MG TABLET [97134]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 64764-677-30
|
| Hospital Charge Code |
1712495
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
FEBUXOSTAT 80 MG TABLET [97134]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 64764-677-30
|
| Hospital Charge Code |
1712495
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.75
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
FEDRATINIB 100 MG CAPSULE [225695]
|
Facility
|
IP
|
$249.16
|
|
|
Service Code
|
NDC 59572-720-12
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.10 |
| Max. Negotiated Rate |
$186.87 |
| Rate for Payer: Adventist Health Commercial |
$49.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$171.17
|
| Rate for Payer: Cash Price |
$112.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$114.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$168.68
|
| Rate for Payer: Heritage Provider Network Senior |
$168.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.29
|
| Rate for Payer: Multiplan Commercial |
$186.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$90.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$83.24
|
|
|
FEDRATINIB 100 MG CAPSULE [225695]
|
Facility
|
OP
|
$249.16
|
|
|
Service Code
|
NDC 59572-720-12
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.10 |
| Max. Negotiated Rate |
$211.79 |
| Rate for Payer: Adventist Health Commercial |
$49.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$133.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$171.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$211.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$137.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$186.87
|
| Rate for Payer: Blue Shield of California Commercial |
$154.73
|
| Rate for Payer: Blue Shield of California EPN |
$146.26
|
| Rate for Payer: Cash Price |
$112.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$114.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$211.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$211.79
|
| Rate for Payer: Dignity Health Senior |
$211.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$115.36
|
| Rate for Payer: Heritage Provider Network Senior |
$115.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$120.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.29
|
| Rate for Payer: Multiplan Commercial |
$186.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$99.66
|
| Rate for Payer: TriValley Medical Group Senior |
$99.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$90.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$83.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$211.79
|
| Rate for Payer: Vantage Medical Group Senior |
$211.79
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$17.64
|
|
|
Service Code
|
NDC 0037-0430-01
|
| Hospital Charge Code |
1711604
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$13.23 |
| Rate for Payer: Adventist Health Commercial |
$3.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.12
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.94
|
| Rate for Payer: Heritage Provider Network Senior |
$11.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$13.23
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 65162-734-09
|
| Hospital Charge Code |
1711604
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 72578-056-01
|
| Hospital Charge Code |
1711604
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.13
|
| Rate for Payer: Heritage Provider Network Senior |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 65162-734-09
|
| Hospital Charge Code |
1711604
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.45
|
| Rate for Payer: Dignity Health Senior |
$2.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Senior |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.45
|
| Rate for Payer: Vantage Medical Group Senior |
$2.45
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
OP
|
$1.67
|
|
|
Service Code
|
NDC 72578-056-01
|
| Hospital Charge Code |
1711604
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.42
|
| Rate for Payer: Dignity Health Senior |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.67
|
| Rate for Payer: TriValley Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: Vantage Medical Group Senior |
$1.42
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
OP
|
$17.64
|
|
|
Service Code
|
NDC 0037-0430-01
|
| Hospital Charge Code |
1711604
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Adventist Health Commercial |
$3.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.23
|
| Rate for Payer: Blue Shield of California Commercial |
$10.95
|
| Rate for Payer: Blue Shield of California EPN |
$10.35
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.99
|
| Rate for Payer: Dignity Health Senior |
$14.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.92
|
| Rate for Payer: Heritage Provider Network Senior |
$10.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$13.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.06
|
| Rate for Payer: TriValley Medical Group Senior |
$7.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.99
|
| Rate for Payer: Vantage Medical Group Senior |
$14.99
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 51525-0442-8
|
| Hospital Charge Code |
1715111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Senior |
$1.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 65162-686-88
|
| Hospital Charge Code |
1715111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 66689-825-08
|
| Hospital Charge Code |
1715111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 51525-0442-8
|
| Hospital Charge Code |
1715111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
IP
|
$9.15
|
|
|
Service Code
|
NDC 0037-0442-67
|
| Hospital Charge Code |
1715111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$6.86 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.29
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.19
|
| Rate for Payer: Heritage Provider Network Senior |
$6.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.29
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 66689-825-08
|
| Hospital Charge Code |
1715111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
