|
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION [41294]
|
Facility
|
OP
|
$130.50
|
|
|
Service Code
|
CPT J9185
|
| Hospital Charge Code |
1755589
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$612.52 |
| Rate for Payer: Adventist Health Commercial |
$26.10
|
| Rate for Payer: Adventist Health Commercial |
$45.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$342.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$342.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$156.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$217.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$217.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$191.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$191.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$191.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$191.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$612.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$612.52
|
| Rate for Payer: Blue Shield of California Commercial |
$104.30
|
| Rate for Payer: Blue Shield of California Commercial |
$104.30
|
| Rate for Payer: Blue Shield of California EPN |
$104.30
|
| Rate for Payer: Blue Shield of California EPN |
$104.30
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cash Price |
$58.73
|
| Rate for Payer: Cash Price |
$58.73
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$104.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.37
|
| Rate for Payer: Dignity Health Senior |
$191.37
|
| Rate for Payer: Dignity Health Senior |
$191.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$173.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$173.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.56
|
| Rate for Payer: Heritage Provider Network Senior |
$105.56
|
| Rate for Payer: Heritage Provider Network Senior |
$60.42
|
| Rate for Payer: Humana Medicare |
$173.97
|
| Rate for Payer: Humana Medicare |
$173.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$278.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$278.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$173.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$173.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$330.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$330.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$205.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$219.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$219.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$219.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$219.20
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
| Rate for Payer: Multiplan Commercial |
$171.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$91.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$52.20
|
| Rate for Payer: TriValley Medical Group Senior |
$91.20
|
| Rate for Payer: TriValley Medical Group Senior |
$52.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$83.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$76.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.37
|
| Rate for Payer: Vantage Medical Group Senior |
$173.97
|
| Rate for Payer: Vantage Medical Group Senior |
$173.97
|
|
|
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION [41294]
|
Facility
|
IP
|
$130.50
|
|
|
Service Code
|
CPT J9185
|
| Hospital Charge Code |
1755589
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$97.88 |
| Rate for Payer: Adventist Health Commercial |
$26.10
|
| Rate for Payer: Adventist Health Commercial |
$45.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$156.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.65
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cash Price |
$58.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$104.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$123.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.35
|
| Rate for Payer: Heritage Provider Network Senior |
$88.35
|
| Rate for Payer: Heritage Provider Network Senior |
$154.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.00
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
| Rate for Payer: Multiplan Commercial |
$171.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$83.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$76.17
|
|
|
FLUDEOXYGLUCOSE F-18 20 MCI TO 200 MCI/ML INTRAVENOUS SOLUTION [222882]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT A9552
|
| Hospital Charge Code |
ERX222882
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.22
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.62
|
| Rate for Payer: Heritage Provider Network Senior |
$40.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.05
|
|
|
FLUDEOXYGLUCOSE F-18 20 MCI TO 200 MCI/ML INTRAVENOUS SOLUTION [222882]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT A9552
|
| Hospital Charge Code |
ERX222882
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$890.46 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$890.46
|
| Rate for Payer: Blue Shield of California Commercial |
$37.26
|
| Rate for Payer: Blue Shield of California EPN |
$35.22
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.00
|
| Rate for Payer: Dignity Health Senior |
$51.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.14
|
| Rate for Payer: Heritage Provider Network Senior |
$37.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$561.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.00
|
| Rate for Payer: Vantage Medical Group Senior |
$51.00
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 0115-7033-02
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 50268-330-11
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.84
|
| Rate for Payer: Dignity Health Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 0555-0997-02
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| 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 |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 0555-0997-02
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| 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 |
$0.50
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 50268-330-11
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 50268-330-15
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 0115-7033-02
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| 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 |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 0115-7033-01
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| 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 |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 50268-330-15
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.84
|
| Rate for Payer: Dignity Health Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 0115-7033-01
|
| Hospital Charge Code |
1710256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
FLUDROCORTISONE ORAL SUSPENSION COMPOUND 0.05 MG/ML [4080275]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-75
|
| Hospital Charge Code |
1715215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
FLUDROCORTISONE ORAL SUSPENSION COMPOUND 0.05 MG/ML [4080275]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-75
|
| Hospital Charge Code |
1715215
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 63323-424-05
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: Dignity Health Senior |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Senior |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 36000-148-01
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 36000-148-10
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 36000-148-10
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 0143-9784-10
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Senior |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| 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 Commercial |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 36000-148-01
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 0143-9784-10
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [10055]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 63323-424-05
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
FLUMAZENIL 0.5 MG/5 ML VIAL - CODE [4080567]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 63323-424-05
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: Dignity Health Senior |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Senior |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
