|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 68084-328-11
|
| Hospital Charge Code |
1712496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.41
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 42858-660-45
|
| Hospital Charge Code |
1712496
|
|
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
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 42858-660-45
|
| Hospital Charge Code |
1712496
|
|
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
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
OP
|
$3.51
|
|
|
Service Code
|
NDC 68084-328-11
|
| Hospital Charge Code |
1712496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.06
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.98
|
| Rate for Payer: Dignity Health Senior |
$2.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Senior |
$1.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.98
|
| Rate for Payer: Vantage Medical Group Senior |
$2.98
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 68084-328-21
|
| Hospital Charge Code |
1712496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.41
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 27241-116-03
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| 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 |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| 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 |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-827-25
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 27241-116-03
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| 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
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-827-25
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 42858-454-45
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 42858-454-45
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-827-95
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 63304-900-90
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-827-95
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 63304-900-90
|
| Hospital Charge Code |
1712510
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
FENOLDOPAM 10 MG/ML INTRAVENOUS SOLUTION [22133]
|
Facility
|
OP
|
$597.48
|
|
|
Service Code
|
NDC 0409-3373-01
|
| Hospital Charge Code |
1759555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.14 |
| Max. Negotiated Rate |
$507.86 |
| Rate for Payer: Adventist Health Commercial |
$119.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$319.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$410.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$507.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$328.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$448.11
|
| Rate for Payer: Blue Shield of California Commercial |
$371.04
|
| Rate for Payer: Blue Shield of California EPN |
$350.72
|
| Rate for Payer: Cash Price |
$268.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$388.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$507.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$507.86
|
| Rate for Payer: Dignity Health Senior |
$507.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$382.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$369.84
|
| Rate for Payer: Heritage Provider Network Senior |
$369.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$287.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.37
|
| Rate for Payer: Multiplan Commercial |
$448.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$238.99
|
| Rate for Payer: TriValley Medical Group Senior |
$238.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$507.86
|
| Rate for Payer: Vantage Medical Group Senior |
$507.86
|
|
|
FENOLDOPAM 10 MG/ML INTRAVENOUS SOLUTION [22133]
|
Facility
|
IP
|
$597.48
|
|
|
Service Code
|
NDC 0409-3373-01
|
| Hospital Charge Code |
1759555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.14 |
| Max. Negotiated Rate |
$448.11 |
| Rate for Payer: Adventist Health Commercial |
$119.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$410.47
|
| Rate for Payer: Cash Price |
$268.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$322.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$404.49
|
| Rate for Payer: Heritage Provider Network Senior |
$404.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.37
|
| Rate for Payer: Multiplan Commercial |
$448.11
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
IP
|
$33.07
|
|
|
Service Code
|
NDC 0406-9100-76
|
| Hospital Charge Code |
1737055
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Adventist Health Commercial |
$6.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.72
|
| Rate for Payer: Cash Price |
$14.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.39
|
| Rate for Payer: Heritage Provider Network Senior |
$22.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
OP
|
$33.07
|
|
|
Service Code
|
NDC 0406-9100-76
|
| Hospital Charge Code |
1737055
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: Adventist Health Commercial |
$6.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.80
|
| Rate for Payer: Blue Shield of California Commercial |
$20.54
|
| Rate for Payer: Blue Shield of California EPN |
$19.41
|
| Rate for Payer: Cash Price |
$14.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.11
|
| Rate for Payer: Dignity Health Senior |
$28.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.47
|
| Rate for Payer: Heritage Provider Network Senior |
$20.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.23
|
| Rate for Payer: TriValley Medical Group Senior |
$13.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.11
|
| Rate for Payer: Vantage Medical Group Senior |
$28.11
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$19.49
|
|
|
Service Code
|
NDC 0406-9112-76
|
| Hospital Charge Code |
1730786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.39
|
| Rate for Payer: Cash Price |
$8.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.19
|
| Rate for Payer: Heritage Provider Network Senior |
$13.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$19.49
|
|
|
Service Code
|
NDC 0406-9112-76
|
| Hospital Charge Code |
1730786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.62
|
| Rate for Payer: Blue Shield of California Commercial |
$12.10
|
| Rate for Payer: Blue Shield of California EPN |
$11.44
|
| Rate for Payer: Cash Price |
$8.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.57
|
| Rate for Payer: Dignity Health Senior |
$16.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.06
|
| Rate for Payer: Heritage Provider Network Senior |
$12.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.80
|
| Rate for Payer: TriValley Medical Group Senior |
$7.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Vantage Medical Group Senior |
$16.57
|
|
|
FENTANYL 1,600 MCG LOZENGE ON A HANDLE [27918]
|
Facility
|
OP
|
$43.11
|
|
|
Service Code
|
NDC 0406-9216-30
|
| Hospital Charge Code |
1730151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$36.64 |
| Rate for Payer: Adventist Health Commercial |
$8.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.33
|
| Rate for Payer: Blue Shield of California Commercial |
$26.77
|
| Rate for Payer: Blue Shield of California EPN |
$25.31
|
| Rate for Payer: Cash Price |
$19.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.64
|
| Rate for Payer: Dignity Health Senior |
$36.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.69
|
| Rate for Payer: Heritage Provider Network Senior |
$26.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.78
|
| Rate for Payer: Multiplan Commercial |
$32.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.24
|
| Rate for Payer: TriValley Medical Group Senior |
$17.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.64
|
| Rate for Payer: Vantage Medical Group Senior |
$36.64
|
|
|
FENTANYL 1,600 MCG LOZENGE ON A HANDLE [27918]
|
Facility
|
IP
|
$43.11
|
|
|
Service Code
|
NDC 0406-9216-30
|
| Hospital Charge Code |
1730151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$32.33 |
| Rate for Payer: Adventist Health Commercial |
$8.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.62
|
| Rate for Payer: Cash Price |
$19.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.19
|
| Rate for Payer: Heritage Provider Network Senior |
$29.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.78
|
| Rate for Payer: Multiplan Commercial |
$32.33
|
|
|
FENTANYL 200 MCG LOZENGE ON A HANDLE [27913]
|
Facility
|
IP
|
$14.62
|
|
|
Service Code
|
NDC 0406-9202-30
|
| Hospital Charge Code |
1730148
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$10.96 |
| Rate for Payer: Adventist Health Commercial |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.04
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.90
|
| Rate for Payer: Heritage Provider Network Senior |
$9.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.66
|
| Rate for Payer: Multiplan Commercial |
$10.96
|
|
|
FENTANYL 200 MCG LOZENGE ON A HANDLE [27913]
|
Facility
|
OP
|
$14.62
|
|
|
Service Code
|
NDC 0406-9202-30
|
| Hospital Charge Code |
1730148
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Adventist Health Commercial |
$2.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.96
|
| Rate for Payer: Blue Shield of California Commercial |
$9.08
|
| Rate for Payer: Blue Shield of California EPN |
$8.58
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.43
|
| Rate for Payer: Dignity Health Senior |
$12.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.05
|
| Rate for Payer: Heritage Provider Network Senior |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.66
|
| Rate for Payer: Multiplan Commercial |
$10.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.85
|
| Rate for Payer: TriValley Medical Group Senior |
$5.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.43
|
| Rate for Payer: Vantage Medical Group Senior |
$12.43
|
|
