|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 65862-621-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
FLECAINIDE ORAL SUSPENSION COMPOUND 20 MG/ML [4080273]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 9994-0802-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.33
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
FLECAINIDE ORAL SUSPENSION COMPOUND 20 MG/ML [4080273]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 9994-0802-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
FLORBETAPIR F-18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [196481]
|
Facility
|
IP
|
$342.12
|
|
|
Service Code
|
HCPCS A9586
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$188.17 |
| Max. Negotiated Rate |
$273.70 |
| Rate for Payer: Cash Price |
$188.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$273.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$205.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.17
|
| Rate for Payer: Multiplan Commercial |
$256.59
|
|
|
FLORBETAPIR F-18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [196481]
|
Facility
|
OP
|
$342.12
|
|
|
Service Code
|
HCPCS A9586
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$188.17 |
| Max. Negotiated Rate |
$273.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$205.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$205.27
|
| Rate for Payer: Cash Price |
$188.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$273.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$205.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$205.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.17
|
| Rate for Payer: Multiplan Commercial |
$256.59
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 57237-004-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 68001-252-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 70710-1138-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 70710-1138-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 57237-004-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 68001-252-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [14232]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 57237-149-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [14232]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 57237-149-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 68001-253-44
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$1.81
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 68001-253-44
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$1.81
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 57237-005-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 57237-005-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [10049]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [10049]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.94
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
NDC 62559-993-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
NDC 62559-993-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 70710-1140-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
