|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
IP
|
$9.71
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.57
|
| Rate for Payer: Heritage Provider Network Senior |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
OP
|
$9.71
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.74
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.25
|
| Rate for Payer: Dignity Health Senior |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.01
|
| Rate for Payer: Heritage Provider Network Senior |
$6.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.80
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.88
|
| Rate for Payer: TriValley Medical Group Senior |
$3.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.25
|
| Rate for Payer: Vantage Medical Group Senior |
$8.25
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 53746-361-01
|
| 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
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 53746-361-01
|
| 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
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| 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 |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| 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 |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| 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 |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| 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
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| 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 |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 5026834611
|
| 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 |
$0.13
|
| 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 |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| 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 |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| 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 |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| 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 |
$0.12
|
| 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
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 5026834615
|
| 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 |
$0.13
|
| 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 |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| 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 |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| 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 |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| 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 |
$0.12
|
| 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
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| 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
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| 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
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 |
$0.18
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 |
$0.18
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$7.67
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$6.52 |
| Rate for Payer: Adventist Health Commercial |
$1.53
|
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.52
|
| Rate for Payer: Dignity Health Senior |
$2.72
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$6.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Senior |
$3.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$5.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$3.07
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$6.52
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Adventist Health Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 9994-0802-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 9994-0802-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| 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 Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$591.00 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$421.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$541.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.72
|
| Rate for Payer: Blue Shield of California Commercial |
$12.89
|
| Rate for Payer: Blue Shield of California EPN |
$12.89
|
| Rate for Payer: Cash Price |
$433.40
|
| Rate for Payer: Cash Price |
$433.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Senior |
$6.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$504.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.84
|
| Rate for Payer: Heritage Provider Network Senior |
$364.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$375.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.59
|
| Rate for Payer: Multiplan Commercial |
$591.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$315.20
|
| Rate for Payer: TriValley Medical Group Senior |
$315.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$284.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$260.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$591.00 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Cash Price |
$433.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$425.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.84
|
| Rate for Payer: Heritage Provider Network Senior |
$364.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.00
|
| Rate for Payer: Multiplan Commercial |
$591.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$284.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$260.91
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]
|
Facility
|
IP
|
$87.15
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$65.36 |
| Rate for Payer: Adventist Health Commercial |
$17.43
|
| Rate for Payer: Cash Price |
$47.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.35
|
| Rate for Payer: Heritage Provider Network Senior |
$40.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.79
|
| Rate for Payer: Multiplan Commercial |
$65.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.86
|
|
