|
FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION [3208]
|
Facility
|
OP
|
$17.05
|
|
|
Service Code
|
NDC 60758-880-05
|
| Hospital Charge Code |
1740244
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.79
|
|
|
FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION [3208]
|
Facility
|
IP
|
$17.05
|
|
|
Service Code
|
NDC 60758-880-05
|
| Hospital Charge Code |
1740244
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$13.64 |
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.79
|
|
|
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION [82204]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
NDG82204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION [82204]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
NDG82204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
NDG82180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
NDG82180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION [82200]
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
1755053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION [82200]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
1755053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.15
|
|
|
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
NDG98249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.50 |
| 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 |
$0.30
|
| 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 Beech St/Commercial/PHCS |
$0.50
|
|
|
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
NDG98249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
|
|
FLUOROURACIL 5 % TOPICAL CREAM [10065]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 0187-3204-47
|
| Hospital Charge Code |
NDG10065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
|
|
FLUOROURACIL 5 % TOPICAL CREAM [10065]
|
Facility
|
OP
|
$3.09
|
|
|
Service Code
|
NDC 51862-362-40
|
| Hospital Charge Code |
NDG10065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.85
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.32
|
|
|
FLUOROURACIL 5 % TOPICAL CREAM [10065]
|
Facility
|
IP
|
$3.09
|
|
|
Service Code
|
NDC 51862-362-40
|
| Hospital Charge Code |
NDG10065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.32
|
|
|
FLUOROURACIL 5 % TOPICAL CREAM [10065]
|
Facility
|
OP
|
$3.09
|
|
|
Service Code
|
NDC 51672-4118-6
|
| Hospital Charge Code |
NDG10065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.85
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.32
|
|
|
FLUOROURACIL 5 % TOPICAL CREAM [10065]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 0187-3204-47
|
| Hospital Charge Code |
NDG10065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
|
|
FLUOROURACIL 5 % TOPICAL CREAM [10065]
|
Facility
|
IP
|
$3.09
|
|
|
Service Code
|
NDC 51672-4118-6
|
| Hospital Charge Code |
NDG10065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.32
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0904-5784-61
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0904-5784-61
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 68001-399-00
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 50111-647-01
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 65862-192-01
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 50111-647-01
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 68001-399-00
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 65862-192-01
|
| Hospital Charge Code |
1711568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 0121-4721-05
|
| Hospital Charge Code |
1716061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.82
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.03
|
|
