|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
IP
|
$188.88
|
|
|
Service Code
|
NDC 6050548332
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.19 |
| Max. Negotiated Rate |
$141.66 |
| Rate for Payer: Adventist Health Commercial |
$37.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$121.64
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$127.87
|
| Rate for Payer: Heritage Provider Network Senior |
$127.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$34.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.22
|
| Rate for Payer: Multiplan Commercial |
$141.66
|
|
|
FIDAXOMICIN 200 MG TABLET [153338]
|
Facility
|
IP
|
$269.83
|
|
|
Service Code
|
NDC 0480259634
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.84 |
| Max. Negotiated Rate |
$202.37 |
| Rate for Payer: Adventist Health Commercial |
$53.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$173.77
|
| Rate for Payer: Cash Price |
$121.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.67
|
| Rate for Payer: Heritage Provider Network Senior |
$182.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.46
|
| Rate for Payer: Multiplan Commercial |
$202.37
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
OP
|
$45.93
|
|
|
Service Code
|
NDC 5201570023
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.97
|
| Rate for Payer: Blue Shield of California Commercial |
$28.02
|
| Rate for Payer: Blue Shield of California EPN |
$22.41
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.43
|
| Rate for Payer: Heritage Provider Network Senior |
$28.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.15
|
| Rate for Payer: Multiplan Commercial |
$34.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.37
|
| Rate for Payer: TriValley Medical Group Senior |
$18.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.04
|
| Rate for Payer: Vantage Medical Group Senior |
$39.04
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
OP
|
$45.93
|
|
|
Service Code
|
NDC 5201570022
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.97
|
| Rate for Payer: Blue Shield of California Commercial |
$28.02
|
| Rate for Payer: Blue Shield of California EPN |
$22.41
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.43
|
| Rate for Payer: Heritage Provider Network Senior |
$28.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.15
|
| Rate for Payer: Multiplan Commercial |
$34.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.37
|
| Rate for Payer: TriValley Medical Group Senior |
$18.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.04
|
| Rate for Payer: Vantage Medical Group Senior |
$39.04
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$45.93
|
|
|
Service Code
|
NDC 5201570023
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$34.45 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.58
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.09
|
| Rate for Payer: Heritage Provider Network Senior |
$31.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.48
|
| Rate for Payer: Multiplan Commercial |
$34.45
|
|
|
FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]
|
Facility
|
IP
|
$45.93
|
|
|
Service Code
|
NDC 5201570022
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$34.45 |
| Rate for Payer: Adventist Health Commercial |
$9.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.58
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.09
|
| Rate for Payer: Heritage Provider Network Senior |
$31.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.48
|
| Rate for Payer: Multiplan Commercial |
$34.45
|
|
|
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [233796]
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$286.20 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$235.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$175.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.68
|
| Rate for Payer: Heritage Provider Network Senior |
$176.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$182.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$69.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$286.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$152.64
|
| Rate for Payer: TriValley Medical Group Senior |
$152.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$126.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [233796]
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.07 |
| Max. Negotiated Rate |
$286.20 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$245.75
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$175.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.68
|
| Rate for Payer: Heritage Provider Network Senior |
$176.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$69.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.40
|
| Rate for Payer: Multiplan Commercial |
$286.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$126.35
|
|
|
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [233797]
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.07 |
| Max. Negotiated Rate |
$286.20 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$245.75
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$175.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.68
|
| Rate for Payer: Heritage Provider Network Senior |
$176.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$69.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.40
|
| Rate for Payer: Multiplan Commercial |
$286.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$126.35
|
|
|
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [233797]
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
HCPCS Q5125
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$286.20 |
| Rate for Payer: Adventist Health Commercial |
$76.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$235.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cash Price |
$171.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$175.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.68
|
| Rate for Payer: Heritage Provider Network Senior |
$176.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$182.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$69.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$286.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$152.64
|
| Rate for Payer: TriValley Medical Group Senior |
$152.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$126.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
OP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$493.85 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$421.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.87
|
| Rate for Payer: Heritage Provider Network Senior |
$304.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$314.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$119.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$493.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$263.39
|
| Rate for Payer: TriValley Medical Group Senior |
$263.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$237.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$218.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]
|
Facility
|
IP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.18 |
| Max. Negotiated Rate |
$493.85 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$424.05
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.87
|
| Rate for Payer: Heritage Provider Network Senior |
$304.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$119.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.62
|
| Rate for Payer: Multiplan Commercial |
$493.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$237.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$218.02
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [211101]
|
Facility
|
OP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$493.85 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$421.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.87
|
| Rate for Payer: Heritage Provider Network Senior |
$304.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$314.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$119.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$493.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$263.39
|
| Rate for Payer: TriValley Medical Group Senior |
$263.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$237.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$218.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [211101]
|
Facility
|
IP
|
$658.47
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.18 |
| Max. Negotiated Rate |
$493.85 |
| Rate for Payer: Adventist Health Commercial |
$131.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$424.05
|
| Rate for Payer: Cash Price |
$296.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.87
|
| Rate for Payer: Heritage Provider Network Senior |
$304.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$119.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.62
|
| Rate for Payer: Multiplan Commercial |
$493.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$237.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$218.02
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
FINASTERIDE (PROSCAR) CRUSHED TABLET IN WATER [4081461]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
FINASTERIDE (PROSCAR) CRUSHED TABLET IN WATER [4081461]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS S0138
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
FINERENONE 10 MG TABLET [232074]
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
NDC 5041954001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.43
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.38
|
| Rate for Payer: Heritage Provider Network Senior |
$19.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.16
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
|
|
FINERENONE 10 MG TABLET [232074]
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
NDC 5041954001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.32
|
| Rate for Payer: Blue Shield of California Commercial |
$17.46
|
| Rate for Payer: Blue Shield of California EPN |
$13.97
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Senior |
$17.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.03
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.45
|
| Rate for Payer: TriValley Medical Group Senior |
$11.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.33
|
| Rate for Payer: Vantage Medical Group Senior |
$24.33
|
|
|
FINERENONE 20 MG TABLET [232075]
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
NDC 5041954101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.43
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.38
|
| Rate for Payer: Heritage Provider Network Senior |
$19.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.16
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
|
|
FINERENONE 20 MG TABLET [232075]
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
NDC 5041954101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.32
|
| Rate for Payer: Blue Shield of California Commercial |
$17.46
|
| Rate for Payer: Blue Shield of California EPN |
$13.97
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Senior |
$17.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.03
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.45
|
| Rate for Payer: TriValley Medical Group Senior |
$11.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.33
|
| Rate for Payer: Vantage Medical Group Senior |
$24.33
|
|
|
FLAVORX LIQUID [100560]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 7857300074
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
FLAVORX LIQUID [100560]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 8606700047
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
FLAVORX LIQUID [100560]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 8606700047
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
