|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 59651-332-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 43386-770-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.40
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 42794-010-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$54.40 |
| Rate for Payer: Cash Price |
$37.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$54.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$40.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.40
|
| Rate for Payer: Multiplan Commercial |
$51.00
|
|
|
FLUCYTOSINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080274]
|
Facility
|
OP
|
$9.38
|
|
|
Service Code
|
NDC 9994-0802-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.63
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.16
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
|
|
FLUCYTOSINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080274]
|
Facility
|
IP
|
$9.38
|
|
|
Service Code
|
NDC 9994-0802-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.16
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
|
|
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 |
$71.78 |
| Max. Negotiated Rate |
$104.40 |
| Rate for Payer: Cash Price |
$71.78
|
| Rate for Payer: Cash Price |
$89.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$130.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$104.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$78.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$97.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.72
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
| Rate for Payer: Multiplan Commercial |
$122.35
|
|
|
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION [41294]
|
Facility
|
OP
|
$163.13
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.72 |
| Max. Negotiated Rate |
$130.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$97.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$78.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$97.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$78.30
|
| Rate for Payer: Cash Price |
$89.72
|
| Rate for Payer: Cash Price |
$71.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$130.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$104.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$78.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$97.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$97.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$78.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.72
|
| Rate for Payer: Multiplan Commercial |
$122.35
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
|
|
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 |
$62.37 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Cash Price |
$62.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$90.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.37
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
|
|
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 |
$62.37 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.04
|
| Rate for Payer: Cash Price |
$62.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$90.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.37
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
|
|
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 |
$33.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
|
|
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 |
$33.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 72603-170-01
|
| 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
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 50268-330-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 50268-330-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 72603-170-01
|
| 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
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 68084-288-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 68084-288-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 70954-252-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 68084-288-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 68084-288-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 0115-7033-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 68084-288-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 0555-0997-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 68084-288-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
|
FLUDROCORTISONE 0.1 MG TABLET [10054]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 50268-330-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
