|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 5965133101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.73
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 5965133101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7.32
|
| Rate for Payer: Blue Shield of California EPN |
$5.86
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.80
|
| Rate for Payer: TriValley Medical Group Senior |
$4.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 4279400908
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.18
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.37
|
| Rate for Payer: Heritage Provider Network Senior |
$24.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 4279400908
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.01
|
| Rate for Payer: Blue Shield of California Commercial |
$21.96
|
| Rate for Payer: Blue Shield of California EPN |
$17.57
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.28
|
| Rate for Payer: Heritage Provider Network Senior |
$22.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.40
|
| Rate for Payer: TriValley Medical Group Senior |
$14.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
NDC 4279401008
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$57.80 |
| Rate for Payer: Adventist Health Commercial |
$13.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.01
|
| Rate for Payer: Blue Shield of California Commercial |
$41.48
|
| Rate for Payer: Blue Shield of California EPN |
$33.18
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$57.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.09
|
| Rate for Payer: Heritage Provider Network Senior |
$42.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$32.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.60
|
| Rate for Payer: Multiplan Commercial |
$51.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.20
|
| Rate for Payer: TriValley Medical Group Senior |
$27.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.80
|
| Rate for Payer: Vantage Medical Group Senior |
$57.80
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 4338677001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 4279401008
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Adventist Health Commercial |
$13.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.79
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.04
|
| Rate for Payer: Heritage Provider Network Senior |
$46.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.00
|
| Rate for Payer: Multiplan Commercial |
$51.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 5965133201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14.64
|
| Rate for Payer: Blue Shield of California EPN |
$11.71
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.86
|
| Rate for Payer: Heritage Provider Network Senior |
$14.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 4338677001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14.64
|
| Rate for Payer: Blue Shield of California EPN |
$11.71
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.86
|
| Rate for Payer: Heritage Provider Network Senior |
$14.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 5965133201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FLUCYTOSINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080274]
|
Facility
|
IP
|
$9.38
|
|
|
Service Code
|
NDC 9994080274
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.04 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.04
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.35
|
| Rate for Payer: Heritage Provider Network Senior |
$6.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
|
|
FLUCYTOSINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080274]
|
Facility
|
OP
|
$9.38
|
|
|
Service Code
|
NDC 9994080274
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California EPN |
$4.58
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.81
|
| Rate for Payer: Heritage Provider Network Senior |
$5.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.57
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.75
|
| Rate for Payer: TriValley Medical Group Senior |
$3.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.97
|
| Rate for Payer: Vantage Medical Group Senior |
$7.97
|
|
|
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION [41294]
|
Facility
|
IP
|
$130.50
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$97.88 |
| Rate for Payer: Adventist Health Commercial |
$26.10
|
| Rate for Payer: Adventist Health Commercial |
$32.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$84.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.06
|
| Rate for Payer: Cash Price |
$58.72
|
| Rate for Payer: Cash Price |
$73.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.53
|
| Rate for Payer: Heritage Provider Network Senior |
$75.53
|
| Rate for Payer: Heritage Provider Network Senior |
$60.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.78
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
| Rate for Payer: Multiplan Commercial |
$122.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$58.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.21
|
|
|
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION [41294]
|
Facility
|
OP
|
$130.50
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$694.79 |
| Rate for Payer: Adventist Health Commercial |
$26.10
|
| Rate for Payer: Adventist Health Commercial |
$32.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$110.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$138.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$89.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$71.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$97.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$122.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$694.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$694.79
|
| Rate for Payer: Blue Shield of California Commercial |
$104.30
|
| Rate for Payer: Blue Shield of California Commercial |
$104.30
|
| Rate for Payer: Blue Shield of California EPN |
$104.30
|
| Rate for Payer: Blue Shield of California EPN |
$104.30
|
| Rate for Payer: Cash Price |
$58.72
|
| Rate for Payer: Cash Price |
$73.41
|
| Rate for Payer: Cash Price |
$58.72
|
| Rate for Payer: Cash Price |
$73.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$138.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$138.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$110.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$110.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$138.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.42
|
| Rate for Payer: Heritage Provider Network Senior |
$75.53
|
| Rate for Payer: Heritage Provider Network Senior |
$60.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$62.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$77.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$114.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$91.35
|
| Rate for Payer: Multiplan Commercial |
$122.35
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$52.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$65.25
|
| Rate for Payer: TriValley Medical Group Senior |
$52.20
|
| Rate for Payer: TriValley Medical Group Senior |
$65.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$58.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$138.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$110.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$138.66
|
| Rate for Payer: Vantage Medical Group Senior |
$138.66
|
| Rate for Payer: Vantage Medical Group Senior |
$110.92
|
|
|
FLUDARABINE 50 MG INTRAVENOUS SOLUTION [10053]
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.53 |
| Max. Negotiated Rate |
$85.05 |
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.03
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.50
|
| Rate for Payer: Heritage Provider Network Senior |
$52.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.35
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.55
|
|
|
FLUDARABINE 50 MG INTRAVENOUS SOLUTION [10053]
|
Facility
|
OP
|
$113.40
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.53 |
| Max. Negotiated Rate |
$694.79 |
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$694.79
|
| Rate for Payer: Blue Shield of California Commercial |
$104.30
|
| Rate for Payer: Blue Shield of California EPN |
$104.30
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.50
|
| Rate for Payer: Heritage Provider Network Senior |
$52.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.38
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.36
|
| Rate for Payer: TriValley Medical Group Senior |
$45.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$96.39
|
|
|
FLUDEOXYGLUCOSE F-18 20 MCI TO 200 MCI/ML INTRAVENOUS SOLUTION [222882]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.64
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.62
|
| Rate for Payer: Heritage Provider Network Senior |
$40.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.87
|
|
|
FLUDEOXYGLUCOSE F-18 20 MCI TO 200 MCI/ML INTRAVENOUS SOLUTION [222882]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$1,010.07 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,010.07
|
| Rate for Payer: Blue Shield of California Commercial |
$36.60
|
| Rate for Payer: Blue Shield of California EPN |
$29.28
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.14
|
| Rate for Payer: Heritage Provider Network Senior |
$37.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.00
|
| Rate for Payer: Vantage Medical Group Senior |
$51.00
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 0115703301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 7260317001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 6808428865
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 6808428801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Vantage Medical Group Senior |
$0.86
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 6808428811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Vantage Medical Group Senior |
$0.86
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 6808428865
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Vantage Medical Group Senior |
$0.83
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 7095425220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
