|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0574060801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 6936716620
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 6936716604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 5789670301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 2055502101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 5789670310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 6936716620
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 2055502101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 5789670310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0574060801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 324/325 MG (65 MG IRON) TABLET. [4083077]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 6936716604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904759080
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904759160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904759080
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]
|
Facility
|
IP
|
$11.60
|
|
|
Service Code
|
NDC 0069-0242-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Adventist Health Commercial |
$2.32
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.85
|
| Rate for Payer: Heritage Provider Network Senior |
$7.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.90
|
| Rate for Payer: Multiplan Commercial |
$8.70
|
|
|
FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]
|
Facility
|
OP
|
$11.60
|
|
|
Service Code
|
NDC 0069-0242-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$9.86 |
| Rate for Payer: Adventist Health Commercial |
$2.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.70
|
| Rate for Payer: Blue Shield of California Commercial |
$7.08
|
| Rate for Payer: Blue Shield of California EPN |
$5.66
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.86
|
| Rate for Payer: Dignity Health Senior |
$9.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.18
|
| Rate for Payer: Heritage Provider Network Senior |
$7.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.12
|
| Rate for Payer: Multiplan Commercial |
$8.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.64
|
| Rate for Payer: TriValley Medical Group Senior |
$4.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.86
|
| Rate for Payer: Vantage Medical Group Senior |
$9.86
|
|
|
FEXOFENADINE 180 MG TABLET [25425]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 41167-4120-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Senior |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
FEXOFENADINE 180 MG TABLET [25425]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 41167-4120-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
FIBRINOGEN-THROMBIN 9.5 CM X 4.8 CM TOPICAL PATCH [105430]
|
Facility
|
OP
|
$843.79
|
|
|
Service Code
|
NDC 0338-8701-00
|
| Min. Negotiated Rate |
$152.73 |
| Max. Negotiated Rate |
$717.22 |
| Rate for Payer: Adventist Health Commercial |
$168.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$451.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$579.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$717.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$464.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$632.84
|
| Rate for Payer: Blue Shield of California Commercial |
$514.71
|
| Rate for Payer: Blue Shield of California EPN |
$411.77
|
| Rate for Payer: Cash Price |
$464.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$548.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$717.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$717.22
|
| Rate for Payer: Dignity Health Senior |
$717.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$548.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$522.31
|
| Rate for Payer: Heritage Provider Network Senior |
$522.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$402.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$210.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$590.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$590.65
|
| Rate for Payer: Multiplan Commercial |
$632.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$421.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$421.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$717.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$717.22
|
| Rate for Payer: Vantage Medical Group Senior |
$717.22
|
|
|
FIBRINOGEN-THROMBIN 9.5 CM X 4.8 CM TOPICAL PATCH [105430]
|
Facility
|
IP
|
$843.79
|
|
|
Service Code
|
NDC 0338-8701-00
|
| Min. Negotiated Rate |
$152.73 |
| Max. Negotiated Rate |
$632.84 |
| Rate for Payer: Adventist Health Commercial |
$168.76
|
| Rate for Payer: Cash Price |
$464.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$571.25
|
| Rate for Payer: Heritage Provider Network Senior |
$571.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$210.95
|
| Rate for Payer: Multiplan Commercial |
$632.84
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
IP
|
$312.30
|
|
|
Service Code
|
NDC 52015-080-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.53 |
| Max. Negotiated Rate |
$234.22 |
| Rate for Payer: Adventist Health Commercial |
$62.46
|
| Rate for Payer: Cash Price |
$171.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.43
|
| Rate for Payer: Heritage Provider Network Senior |
$211.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.08
|
| Rate for Payer: Multiplan Commercial |
$234.22
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
OP
|
$312.30
|
|
|
Service Code
|
NDC 52015-080-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.53 |
| Max. Negotiated Rate |
$265.45 |
| Rate for Payer: Adventist Health Commercial |
$62.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$166.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$214.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$265.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$171.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$234.22
|
| Rate for Payer: Blue Shield of California Commercial |
$190.50
|
| Rate for Payer: Blue Shield of California EPN |
$152.40
|
| Rate for Payer: Cash Price |
$171.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$203.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$265.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$265.45
|
| Rate for Payer: Dignity Health Senior |
$265.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$193.31
|
| Rate for Payer: Heritage Provider Network Senior |
$193.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$148.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$218.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$218.61
|
| Rate for Payer: Multiplan Commercial |
$234.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$124.92
|
| Rate for Payer: TriValley Medical Group Senior |
$124.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$156.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$265.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$265.45
|
| Rate for Payer: Vantage Medical Group Senior |
$265.45
|
|
