|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
OP
|
$8.56
|
|
|
Service Code
|
NDC 0406-9125-76
|
| Hospital Charge Code |
1737052
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.42
|
| Rate for Payer: Blue Shield of California Commercial |
$5.32
|
| Rate for Payer: Blue Shield of California EPN |
$5.02
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.28
|
| Rate for Payer: Dignity Health Senior |
$7.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.30
|
| Rate for Payer: Heritage Provider Network Senior |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.42
|
| Rate for Payer: TriValley Medical Group Senior |
$3.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
IP
|
$8.56
|
|
|
Service Code
|
NDC 0406-9125-76
|
| Hospital Charge Code |
1737052
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.88
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
|
|
FENTANYL 400 MCG LOZENGE ON A HANDLE [27914]
|
Facility
|
OP
|
$18.53
|
|
|
Service Code
|
NDC 0406-9204-30
|
| Hospital Charge Code |
1730147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Adventist Health Commercial |
$3.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.90
|
| Rate for Payer: Blue Shield of California Commercial |
$11.51
|
| Rate for Payer: Blue Shield of California EPN |
$10.88
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.75
|
| Rate for Payer: Dignity Health Senior |
$15.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.47
|
| Rate for Payer: Heritage Provider Network Senior |
$11.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$13.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.41
|
| Rate for Payer: TriValley Medical Group Senior |
$7.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.75
|
| Rate for Payer: Vantage Medical Group Senior |
$15.75
|
|
|
FENTANYL 400 MCG LOZENGE ON A HANDLE [27914]
|
Facility
|
IP
|
$18.53
|
|
|
Service Code
|
NDC 0406-9204-30
|
| Hospital Charge Code |
1730147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$13.90 |
| Rate for Payer: Adventist Health Commercial |
$3.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.73
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.54
|
| Rate for Payer: Heritage Provider Network Senior |
$12.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$13.90
|
|
|
FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 0406-9150-76
|
| Hospital Charge Code |
1737053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Adventist Health Commercial |
$3.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.44
|
| Rate for Payer: Blue Shield of California EPN |
$8.92
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.92
|
| Rate for Payer: Dignity Health Senior |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.41
|
| Rate for Payer: Heritage Provider Network Senior |
$9.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$11.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.08
|
| Rate for Payer: TriValley Medical Group Senior |
$6.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.92
|
| Rate for Payer: Vantage Medical Group Senior |
$12.92
|
|
|
FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 0406-9050-76
|
| Hospital Charge Code |
1737053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Adventist Health Commercial |
$3.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.44
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.29
|
| Rate for Payer: Heritage Provider Network Senior |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$11.40
|
|
|
FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 0406-9150-76
|
| Hospital Charge Code |
1737053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Adventist Health Commercial |
$3.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.44
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.29
|
| Rate for Payer: Heritage Provider Network Senior |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$11.40
|
|
|
FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 0406-9050-76
|
| Hospital Charge Code |
1737053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Adventist Health Commercial |
$3.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.44
|
| Rate for Payer: Blue Shield of California EPN |
$8.92
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.92
|
| Rate for Payer: Dignity Health Senior |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.41
|
| Rate for Payer: Heritage Provider Network Senior |
$9.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$11.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.08
|
| Rate for Payer: TriValley Medical Group Senior |
$6.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.92
|
| Rate for Payer: Vantage Medical Group Senior |
$12.92
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
IP
|
$24.02
|
|
|
Service Code
|
NDC 0378-9123-98
|
| Hospital Charge Code |
1737054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$18.02 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.50
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.26
|
| Rate for Payer: Heritage Provider Network Senior |
$16.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.02
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
IP
|
$24.02
|
|
|
Service Code
|
NDC 0378-9123-16
|
| Hospital Charge Code |
1737054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$18.02 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.50
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.26
|
| Rate for Payer: Heritage Provider Network Senior |
$16.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.02
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
OP
|
$24.02
|
|
|
Service Code
|
NDC 0378-9123-98
|
| Hospital Charge Code |
1737054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$20.42 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.02
|
| Rate for Payer: Blue Shield of California Commercial |
$14.92
|
| Rate for Payer: Blue Shield of California EPN |
$14.10
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.42
|
| Rate for Payer: Dignity Health Senior |
$20.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.87
|
| Rate for Payer: Heritage Provider Network Senior |
$14.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.61
|
| Rate for Payer: TriValley Medical Group Senior |
$9.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.42
|
| Rate for Payer: Vantage Medical Group Senior |
$20.42
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
OP
|
$24.02
|
|
|
Service Code
|
NDC 0378-9123-16
|
| Hospital Charge Code |
1737054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$20.42 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.02
|
| Rate for Payer: Blue Shield of California Commercial |
$14.92
|
| Rate for Payer: Blue Shield of California EPN |
$14.10
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.42
|
| Rate for Payer: Dignity Health Senior |
$20.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.87
|
| Rate for Payer: Heritage Provider Network Senior |
$14.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.61
|
| Rate for Payer: TriValley Medical Group Senior |
$9.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.42
|
| Rate for Payer: Vantage Medical Group Senior |
$20.42
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
IP
|
$24.02
|
|
|
Service Code
|
NDC 0406-9175-76
|
| Hospital Charge Code |
1737054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$18.02 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.50
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.26
|
| Rate for Payer: Heritage Provider Network Senior |
$16.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.02
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
OP
|
$24.02
|
|
|
Service Code
|
NDC 0406-9175-76
|
| Hospital Charge Code |
1737054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$20.42 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.02
|
| Rate for Payer: Blue Shield of California Commercial |
$14.92
|
| Rate for Payer: Blue Shield of California EPN |
$14.10
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.42
|
| Rate for Payer: Dignity Health Senior |
$20.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.87
|
| Rate for Payer: Heritage Provider Network Senior |
$14.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.61
|
| Rate for Payer: TriValley Medical Group Senior |
$9.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.42
|
| Rate for Payer: Vantage Medical Group Senior |
$20.42
|
|
|
FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX ADULT [4081452]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 71286-2081-1
|
| Hospital Charge Code |
NDG2569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX ADULT [4081452]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 71286-2081-1
|
| Hospital Charge Code |
NDG2569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 71286-2081-1
|
| Hospital Charge Code |
NDG2569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 71286-2081-1
|
| Hospital Charge Code |
NDG2569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 70004-244-40
|
| Hospital Charge Code |
NDG2569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 70004-244-40
|
| Hospital Charge Code |
NDG2569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
FENTANYL (PF) 1,500 MCG/30 ML (50 MCG/ML) PCA INTRAVENOUS SOLUTION [121423]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
CPT J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Senior |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
FENTANYL (PF) 1,500 MCG/30 ML (50 MCG/ML) PCA INTRAVENOUS SOLUTION [121423]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
CPT J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.48
|
|
|
FENTANYL (PF) 2,750 MCG/55 ML (50 MCG/ML) INTRAVENOUS PCA SYRINGE [117731]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
NDG117731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| 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 |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
|
|
FENTANYL (PF) 2,750 MCG/55 ML (50 MCG/ML) INTRAVENOUS PCA SYRINGE [117731]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
NDG117731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| 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 |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
FENTANYL (PF) 500 MCG/50 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE [121190]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
NDG408121190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Senior |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
