|
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [14232]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 57237-149-35
|
| Hospital Charge Code |
1715959
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.52
|
|
|
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [14232]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 57237-149-35
|
| Hospital Charge Code |
1715959
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.52 |
| 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 |
$0.31
|
| 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 Beech St/Commercial/PHCS |
$0.52
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 68001-253-20
|
| Hospital Charge Code |
1711795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.82 |
| 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 |
$1.09
|
| 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 Beech St/Commercial/PHCS |
$1.82
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 68001-253-44
|
| Hospital Charge Code |
1711795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.82
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 68001-253-20
|
| Hospital Charge Code |
1711795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.82
|
|
|
FLUCONAZOLE 150 MG TABLET [13577]
|
Facility
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 68001-253-44
|
| Hospital Charge Code |
1711795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.82 |
| 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 |
$1.09
|
| 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 Beech St/Commercial/PHCS |
$1.82
|
|
|
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [10049]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
CPT J1450
|
| Hospital Charge Code |
NDG10049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| 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 EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [10049]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
CPT J1450
|
| Hospital Charge Code |
NDG10049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| 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: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 67405-604-03
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-11
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.42 |
| 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 |
$1.45
|
| 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 Beech St/Commercial/PHCS |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 0172-5413-46
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$75.11
|
|
|
Service Code
|
NDC 0049-3430-41
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.31 |
| Max. Negotiated Rate |
$60.09 |
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$56.33
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 68462-104-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 0172-5413-46
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268-339-11
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.25
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 0904-6501-61
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.84
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$75.11
|
|
|
Service Code
|
NDC 0049-3430-41
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.31 |
| Max. Negotiated Rate |
$56.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$45.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$45.07
|
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$45.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$56.33
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 67405-604-03
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 70710-1140-3
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$2.59
|
|
|
Service Code
|
NDC 59762-5018-1
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.94
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$2.59
|
|
|
Service Code
|
NDC 59762-5018-1
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.94
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-01
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
NDC 62559-993-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.59 |
| 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 |
$0.36
|
| 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 Beech St/Commercial/PHCS |
$0.59
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 55111-146-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.60
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-01
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.42 |
| 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 |
$1.45
|
| 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 Beech St/Commercial/PHCS |
$2.42
|
|
