|
FASCIOTOMY, FOOT AND/OR TOE
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 28008
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
FAT EMULSION 20 % INTRAVENOUS [10014]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| 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 |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
FAT EMULSION 20 % INTRAVENOUS [10014]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
|
|
FAT EMULSION 20 % IV RATE BASED [40840048]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| 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 |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| 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
|
|
|
FAT EMULSION 20 % IV RATE BASED [40840048]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 6332382000
|
| Hospital Charge Code |
901700008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| 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 |
$0.14
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 6332382001
|
| Hospital Charge Code |
901700008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 6332382001
|
| Hospital Charge Code |
901700008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| 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 |
$0.14
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [215468]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 6332382000
|
| Hospital Charge Code |
901700008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 7220502830
|
| 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: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| 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 Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 6068753821
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 7220502830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 6233219030
|
| 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: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| 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 Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 6068753821
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 6068753811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 6233219030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 3334227407
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 6068753811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
FEBUXOSTAT 40 MG TABLET [97133]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 3334227407
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| 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 |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| 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
|
|
|
FEBUXOSTAT 80 MG TABLET [97134]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 6476467730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.50
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
FEBUXOSTAT 80 MG TABLET [97134]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 6476467730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
FEDRATINIB 100 MG CAPSULE [225695]
|
Facility
|
IP
|
$288.42
|
|
|
Service Code
|
NDC 5957272012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.20 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Adventist Health Commercial |
$57.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$185.74
|
| Rate for Payer: Cash Price |
$129.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$155.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$195.26
|
| Rate for Payer: Heritage Provider Network Senior |
$195.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.11
|
| Rate for Payer: Multiplan Commercial |
$216.31
|
|
|
FEDRATINIB 100 MG CAPSULE [225695]
|
Facility
|
OP
|
$288.42
|
|
|
Service Code
|
NDC 5957272012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.20 |
| Max. Negotiated Rate |
$245.16 |
| Rate for Payer: Adventist Health Commercial |
$57.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$178.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$245.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$158.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$216.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$144.27
|
| Rate for Payer: Blue Shield of California Commercial |
$175.94
|
| Rate for Payer: Blue Shield of California EPN |
$140.75
|
| Rate for Payer: Cash Price |
$129.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$187.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$245.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$245.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$245.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$184.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$178.53
|
| Rate for Payer: Heritage Provider Network Senior |
$178.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$137.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$201.89
|
| Rate for Payer: Multiplan Commercial |
$216.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$115.37
|
| Rate for Payer: TriValley Medical Group Senior |
$115.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$144.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$144.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$245.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$245.16
|
| Rate for Payer: Vantage Medical Group Senior |
$245.16
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 7257805601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.08
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.13
|
| Rate for Payer: Heritage Provider Network Senior |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
FELBAMATE 400 MG TABLET [10024]
|
Facility
|
IP
|
$18.52
|
|
|
Service Code
|
NDC 0037043001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$13.89 |
| Rate for Payer: Adventist Health Commercial |
$3.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.93
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.54
|
| Rate for Payer: Heritage Provider Network Senior |
$12.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$13.89
|
|
