|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$18.52
|
|
|
Service Code
|
NDC 0037-0430-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$13.89 |
| Rate for Payer: Adventist Health Commercial |
$3.70
|
| Rate for Payer: Cash Price |
$10.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.00
|
| 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 |
$13.89
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 65162-734-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 72578-056-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.13
|
| Rate for Payer: Heritage Provider Network Senior |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
OP
|
$1.67
|
|
|
Service Code
|
NDC 72578-056-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.42
|
| Rate for Payer: Dignity Health Senior |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.67
|
| Rate for Payer: TriValley Medical Group Senior |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: Vantage Medical Group Senior |
$1.42
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 51525-0442-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 65162-686-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 51525-0442-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Senior |
$1.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 65162-686-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Senior |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
FELBAMATE 600 MG TABLET [10025]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 62559-731-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
FELBAMATE 600 MG TABLET [10025]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 62559-731-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
FELODIPINE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [27491]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 53489-370-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Senior |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
FELODIPINE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [27491]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 53489-370-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 57237-108-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.55 |
| 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 |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: Dignity Health Senior |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 68462-233-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| 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
|
|
|
FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 57237-108-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| 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 Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
|
|
FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 68462-233-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| 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: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 27241-117-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 42858-660-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| 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 |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| 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 |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 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: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$2.87
|
|
|
Service Code
|
NDC 60687-864-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
OP
|
$2.87
|
|
|
Service Code
|
NDC 60687-864-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.44
|
| Rate for Payer: Dignity Health Senior |
$2.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.01
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Senior |
$1.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2.44
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
OP
|
$2.87
|
|
|
Service Code
|
NDC 60687-864-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.44
|
| Rate for Payer: Dignity Health Senior |
$2.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.01
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Senior |
$1.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2.44
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 42858-660-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| 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
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 27241-117-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
FENOFIBRATE 160 MG TABLET [28252]
|
Facility
|
IP
|
$2.87
|
|
|
Service Code
|
NDC 60687-864-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 27241-116-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
