|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA 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: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| 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 |
$0.16
|
| 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 |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| 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 |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA 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: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| 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 |
$0.16
|
| 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 |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| 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 |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$5.33
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Blue Shield of California EPN |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$4.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Senior |
$3.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$7.43
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$8.74
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$4.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 9994080276
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 9994080276
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.20 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Adventist Health Commercial |
$240.00
|
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$507.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$772.80
|
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$552.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$648.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$425.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$555.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.84
|
| Rate for Payer: Heritage Provider Network Senior |
$364.84
|
| Rate for Payer: Heritage Provider Network Senior |
$555.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$142.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$217.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.00
|
| Rate for Payer: Multiplan Commercial |
$591.00
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$433.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$284.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$260.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$397.32
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$591.00 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Adventist Health Commercial |
$240.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$741.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$486.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.67
|
| Rate for Payer: Blue Shield of California Commercial |
$12.89
|
| Rate for Payer: Blue Shield of California Commercial |
$12.89
|
| Rate for Payer: Blue Shield of California EPN |
$12.89
|
| Rate for Payer: Blue Shield of California EPN |
$12.89
|
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$552.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$504.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$768.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.18
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$555.60
|
| Rate for Payer: Heritage Provider Network Senior |
$364.84
|
| Rate for Payer: Heritage Provider Network Senior |
$555.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$375.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$572.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$217.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$142.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$591.00
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$480.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$315.20
|
| Rate for Payer: TriValley Medical Group Senior |
$480.00
|
| Rate for Payer: TriValley Medical Group Senior |
$315.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$284.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$433.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$260.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$397.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]
|
Facility
|
OP
|
$87.15
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$74.08 |
| Rate for Payer: Adventist Health Commercial |
$17.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$74.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$74.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.35
|
| Rate for Payer: Heritage Provider Network Senior |
$40.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$41.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$61.01
|
| Rate for Payer: Multiplan Commercial |
$65.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$34.86
|
| Rate for Payer: TriValley Medical Group Senior |
$34.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$74.08
|
| Rate for Payer: Vantage Medical Group Senior |
$74.08
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]
|
Facility
|
IP
|
$87.15
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$65.36 |
| Rate for Payer: Adventist Health Commercial |
$17.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.12
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.35
|
| Rate for Payer: Heritage Provider Network Senior |
$40.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.79
|
| Rate for Payer: Multiplan Commercial |
$65.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.86
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
OP
|
$59.66
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$50.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.62
|
| Rate for Payer: Heritage Provider Network Senior |
$27.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41.76
|
| Rate for Payer: Multiplan Commercial |
$44.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.86
|
| Rate for Payer: TriValley Medical Group Senior |
$23.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.71
|
| Rate for Payer: Vantage Medical Group Senior |
$50.71
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
IP
|
$59.66
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$44.74 |
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.42
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.62
|
| Rate for Payer: Heritage Provider Network Senior |
$27.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: Multiplan Commercial |
$44.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.75
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
OP
|
$108.64
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$92.34 |
| Rate for Payer: Adventist Health Commercial |
$21.73
|
| Rate for Payer: Adventist Health Commercial |
$22.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$67.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$92.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$94.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$94.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$92.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$94.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.30
|
| Rate for Payer: Heritage Provider Network Senior |
$51.21
|
| Rate for Payer: Heritage Provider Network Senior |
$50.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$51.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$52.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$77.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$76.05
|
| Rate for Payer: Multiplan Commercial |
$82.95
|
| Rate for Payer: Multiplan Commercial |
$81.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.24
|
| Rate for Payer: TriValley Medical Group Senior |
$43.46
|
| Rate for Payer: TriValley Medical Group Senior |
$44.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$94.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$92.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.01
|
| Rate for Payer: Vantage Medical Group Senior |
$94.01
|
| Rate for Payer: Vantage Medical Group Senior |
$92.34
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
IP
|
$108.64
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Adventist Health Commercial |
$21.73
|
| Rate for Payer: Adventist Health Commercial |
$22.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.23
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.21
|
| Rate for Payer: Heritage Provider Network Senior |
$51.21
|
| Rate for Payer: Heritage Provider Network Senior |
$50.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.65
|
| Rate for Payer: Multiplan Commercial |
$81.48
|
| Rate for Payer: Multiplan Commercial |
$82.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.97
|
|
|
FOOT PROCEDURES WITH CC
|
Facility
|
IP
|
$29,404.05
|
|
|
Service Code
|
MSDRG 504
|
| Min. Negotiated Rate |
$21,943.32 |
| Max. Negotiated Rate |
$29,404.05 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,943.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,943.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25,234.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$29,404.05
|
|
|
FOOT PROCEDURES WITH MCC
|
Facility
|
IP
|
$43,560.24
|
|
|
Service Code
|
MSDRG 503
|
| Min. Negotiated Rate |
$32,507.64 |
| Max. Negotiated Rate |
$43,560.24 |
| Rate for Payer: EPIC Health Plan Medicare |
$32,507.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32,507.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$37,383.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43,560.24
|
|
|
FOOT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$28,230.88
|
|
|
Service Code
|
MSDRG 505
|
| Min. Negotiated Rate |
$21,067.82 |
| Max. Negotiated Rate |
$28,230.88 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,067.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,067.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,227.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,230.88
|
|
|
FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15576
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
IP
|
$12.66
|
|
|
Service Code
|
NDC 4950260530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.15
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.57
|
| Rate for Payer: Heritage Provider Network Senior |
$8.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
OP
|
$12.66
|
|
|
Service Code
|
NDC 4950260595
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$10.76 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.33
|
| Rate for Payer: Blue Shield of California Commercial |
$7.72
|
| Rate for Payer: Blue Shield of California EPN |
$6.18
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.84
|
| Rate for Payer: Heritage Provider Network Senior |
$7.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.86
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.06
|
| Rate for Payer: TriValley Medical Group Senior |
$5.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.76
|
| Rate for Payer: Vantage Medical Group Senior |
$10.76
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
OP
|
$12.66
|
|
|
Service Code
|
NDC 4950260530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$10.76 |
| Rate for Payer: Vantage Medical Group Senior |
$10.76
|
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.33
|
| Rate for Payer: Blue Shield of California Commercial |
$7.72
|
| Rate for Payer: Blue Shield of California EPN |
$6.18
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.84
|
| Rate for Payer: Heritage Provider Network Senior |
$7.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.86
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.06
|
| Rate for Payer: TriValley Medical Group Senior |
$5.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.76
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
IP
|
$12.66
|
|
|
Service Code
|
NDC 4950260595
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.15
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.57
|
| Rate for Payer: Heritage Provider Network Senior |
$8.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
|
