|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.45
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.45 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.45
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
IP
|
$9.72
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
ERX91129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.29
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
OP
|
$9.72
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
ERX91129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.83
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.29
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 53746-361-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| Hospital Charge Code |
1710248
|
|
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
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 53746-361-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| 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 |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-11
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.16 |
| 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: Cash Price |
$0.09
|
| 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: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.16 |
| 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: Cash Price |
$0.09
|
| 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: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-11
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| Hospital Charge Code |
1710248
|
|
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
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$5.90
|
|
|
Service Code
|
NDC 63323-184-10
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.42
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 63323-184-11
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.40
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 39822-1100-1
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 63323-184-11
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.92
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.40
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 39822-1100-1
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$5.90
|
|
|
Service Code
|
NDC 63323-184-10
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.54
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.42
|
|
