|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 63304-900-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| 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 |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 63304-900-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 42858-454-45
|
| 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 |
$0.12
|
| 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
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 27241-116-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
FENOFIBRATE 54 MG TABLET [31336]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 42858-454-45
|
| 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
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
IP
|
$33.07
|
|
|
Service Code
|
NDC 0406-9100-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Adventist Health Commercial |
$6.61
|
| Rate for Payer: Cash Price |
$18.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.39
|
| Rate for Payer: Heritage Provider Network Senior |
$22.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
OP
|
$33.07
|
|
|
Service Code
|
NDC 0406-9100-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: Adventist Health Commercial |
$6.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.80
|
| Rate for Payer: Blue Shield of California Commercial |
$20.17
|
| Rate for Payer: Blue Shield of California EPN |
$16.14
|
| Rate for Payer: Cash Price |
$18.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.11
|
| Rate for Payer: Dignity Health Senior |
$28.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.47
|
| Rate for Payer: Heritage Provider Network Senior |
$20.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.15
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.23
|
| Rate for Payer: TriValley Medical Group Senior |
$13.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.11
|
| Rate for Payer: Vantage Medical Group Senior |
$28.11
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$19.49
|
|
|
Service Code
|
NDC 0406-9112-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.62
|
| Rate for Payer: Blue Shield of California Commercial |
$11.89
|
| Rate for Payer: Blue Shield of California EPN |
$9.51
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.57
|
| Rate for Payer: Dignity Health Senior |
$16.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.06
|
| Rate for Payer: Heritage Provider Network Senior |
$12.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.64
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.80
|
| Rate for Payer: TriValley Medical Group Senior |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Vantage Medical Group Senior |
$16.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$19.49
|
|
|
Service Code
|
NDC 0406-9112-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.19
|
| Rate for Payer: Heritage Provider Network Senior |
$13.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$19.49
|
|
|
Service Code
|
NDC 47781-423-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.19
|
| Rate for Payer: Heritage Provider Network Senior |
$13.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$19.49
|
|
|
Service Code
|
NDC 47781-423-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.19
|
| Rate for Payer: Heritage Provider Network Senior |
$13.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$19.49
|
|
|
Service Code
|
NDC 47781-423-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.62
|
| Rate for Payer: Blue Shield of California Commercial |
$11.89
|
| Rate for Payer: Blue Shield of California EPN |
$9.51
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.57
|
| Rate for Payer: Dignity Health Senior |
$16.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.06
|
| Rate for Payer: Heritage Provider Network Senior |
$12.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.64
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.80
|
| Rate for Payer: TriValley Medical Group Senior |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Vantage Medical Group Senior |
$16.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$5.28
|
|
|
Service Code
|
NDC 50742-549-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.49
|
| Rate for Payer: Dignity Health Senior |
$4.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Senior |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.11
|
| Rate for Payer: TriValley Medical Group Senior |
$2.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.49
|
| Rate for Payer: Vantage Medical Group Senior |
$4.49
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$5.28
|
|
|
Service Code
|
NDC 50742-549-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.57
|
| Rate for Payer: Heritage Provider Network Senior |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$5.28
|
|
|
Service Code
|
NDC 50742-549-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.57
|
| Rate for Payer: Heritage Provider Network Senior |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$5.28
|
|
|
Service Code
|
NDC 50742-549-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.49
|
| Rate for Payer: Dignity Health Senior |
$4.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Senior |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.11
|
| Rate for Payer: TriValley Medical Group Senior |
$2.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.49
|
| Rate for Payer: Vantage Medical Group Senior |
$4.49
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$19.49
|
|
|
Service Code
|
NDC 47781-423-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.62
|
| Rate for Payer: Blue Shield of California Commercial |
$11.89
|
| Rate for Payer: Blue Shield of California EPN |
$9.51
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.57
|
| Rate for Payer: Dignity Health Senior |
$16.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.06
|
| Rate for Payer: Heritage Provider Network Senior |
$12.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.64
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.80
|
| Rate for Payer: TriValley Medical Group Senior |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Vantage Medical Group Senior |
$16.57
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
OP
|
$8.56
|
|
|
Service Code
|
NDC 0406-9125-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.42
|
| Rate for Payer: Blue Shield of California Commercial |
$5.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.18
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.28
|
| Rate for Payer: Dignity Health Senior |
$7.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.30
|
| Rate for Payer: Heritage Provider Network Senior |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.99
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.42
|
| Rate for Payer: TriValley Medical Group Senior |
$3.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
OP
|
$8.56
|
|
|
Service Code
|
NDC 0378-9121-98
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.42
|
| Rate for Payer: Blue Shield of California Commercial |
$5.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.18
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.28
|
| Rate for Payer: Dignity Health Senior |
$7.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.30
|
| Rate for Payer: Heritage Provider Network Senior |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.99
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.42
|
| Rate for Payer: TriValley Medical Group Senior |
$3.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 50742-550-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
IP
|
$8.56
|
|
|
Service Code
|
NDC 0406-9125-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 50742-550-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
IP
|
$8.56
|
|
|
Service Code
|
NDC 0378-9121-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
IP
|
$8.56
|
|
|
Service Code
|
NDC 0378-9121-98
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.42
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 50742-550-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
