|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 6936716620
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| 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 |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| 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 5789670310
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| 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: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| 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
|
$0.06
|
|
|
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: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 6936716620
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 2055502101
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
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: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| 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: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| 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
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 2055502101
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.02
|
| 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/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| 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
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 5789670301
|
| Hospital Charge Code |
1710172
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.02
|
| 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/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
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: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| 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: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$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: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$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
|
|
|
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 |
$2.73 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Adventist Health Commercial |
$3.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.35
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.20
|
| Rate for Payer: Heritage Provider Network Senior |
$10.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: Multiplan Commercial |
$11.30
|
|
|
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 |
$2.73 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: Adventist Health Commercial |
$3.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.35
|
| 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 |
$11.30
|
| Rate for Payer: Blue Shield of California Commercial |
$9.35
|
| Rate for Payer: Blue Shield of California EPN |
$8.84
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.80
|
| Rate for Payer: Dignity Health Senior |
$12.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.32
|
| Rate for Payer: Heritage Provider Network Senior |
$9.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: Multiplan Commercial |
$11.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.02
|
| Rate for Payer: TriValley Medical Group Senior |
$6.02
|
| 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
|
$3,335.88
|
|
|
Service Code
|
APR-DRG 7221
|
| Min. Negotiated Rate |
$3,335.88 |
| Max. Negotiated Rate |
$3,335.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,335.88
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$6,821.01
|
|
|
Service Code
|
APR-DRG 7223
|
| Min. Negotiated Rate |
$6,821.01 |
| Max. Negotiated Rate |
$6,821.01 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,821.01
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$9,901.20
|
|
|
Service Code
|
APR-DRG 7224
|
| Min. Negotiated Rate |
$9,901.20 |
| Max. Negotiated Rate |
$9,901.20 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,901.20
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$5,005.32
|
|
|
Service Code
|
APR-DRG 7222
|
| Min. Negotiated Rate |
$5,005.32 |
| Max. Negotiated Rate |
$5,005.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,005.32
|
|
|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| 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 |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Senior |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| 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 |
$51.03 |
| Max. Negotiated Rate |
$239.64 |
| Rate for Payer: Adventist Health Commercial |
$56.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$150.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.69
|
| 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 |
$211.45
|
| Rate for Payer: Blue Shield of California Commercial |
$175.08
|
| Rate for Payer: Blue Shield of California EPN |
$165.49
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$183.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.64
|
| Rate for Payer: Dignity Health Senior |
$239.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$174.51
|
| Rate for Payer: Heritage Provider Network Senior |
$174.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.48
|
| Rate for Payer: Multiplan Commercial |
$211.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$112.77
|
| Rate for Payer: TriValley Medical Group Senior |
$112.77
|
| 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 |
$51.03 |
| Max. Negotiated Rate |
$211.45 |
| Rate for Payer: Adventist Health Commercial |
$56.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.69
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.87
|
| Rate for Payer: Heritage Provider Network Senior |
$190.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.48
|
| Rate for Payer: Multiplan Commercial |
$211.45
|
|
|
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 |
$7.50 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Adventist Health Commercial |
$8.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| 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 |
$31.10
|
| Rate for Payer: Blue Shield of California Commercial |
$25.75
|
| Rate for Payer: Blue Shield of California EPN |
$24.34
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.24
|
| Rate for Payer: Dignity Health Senior |
$35.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.66
|
| Rate for Payer: Heritage Provider Network Senior |
$25.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.36
|
| Rate for Payer: Multiplan Commercial |
$31.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.58
|
| Rate for Payer: TriValley Medical Group Senior |
$16.58
|
| 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 |
$7.50 |
| Max. Negotiated Rate |
$31.10 |
| Rate for Payer: Adventist Health Commercial |
$8.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.07
|
| Rate for Payer: Heritage Provider Network Senior |
$28.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.36
|
| Rate for Payer: Multiplan Commercial |
$31.10
|
|
|
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 |
$7.50 |
| Max. Negotiated Rate |
$31.10 |
| Rate for Payer: Adventist Health Commercial |
$8.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.07
|
| Rate for Payer: Heritage Provider Network Senior |
$28.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.36
|
| Rate for Payer: Multiplan Commercial |
$31.10
|
|
|
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 |
$7.50 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Adventist Health Commercial |
$8.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| 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 |
$31.10
|
| Rate for Payer: Blue Shield of California Commercial |
$25.75
|
| Rate for Payer: Blue Shield of California EPN |
$24.34
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.24
|
| Rate for Payer: Dignity Health Senior |
$35.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.66
|
| Rate for Payer: Heritage Provider Network Senior |
$25.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.36
|
| Rate for Payer: Multiplan Commercial |
$31.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.58
|
| Rate for Payer: TriValley Medical Group Senior |
$16.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.24
|
| Rate for Payer: Vantage Medical Group Senior |
$35.24
|
|
