|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 69238-1679-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Senior |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]
|
Facility
|
OP
|
$29.04
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$60.64 |
| Rate for Payer: Adventist Health Commercial |
$5.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.64
|
| Rate for Payer: Blue Shield of California Commercial |
$27.43
|
| Rate for Payer: Blue Shield of California EPN |
$27.43
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO |
$20.33
|
| Rate for Payer: Cigna of CA PPO |
$20.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.62
|
| Rate for Payer: EPIC Health Plan Senior |
$11.62
|
| Rate for Payer: Galaxy Health WC |
$24.68
|
| Rate for Payer: Global Benefits Group Commercial |
$17.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.33
|
| Rate for Payer: Multiplan Commercial |
$23.23
|
| Rate for Payer: Networks By Design Commercial |
$14.52
|
| Rate for Payer: Prime Health Services Commercial |
$24.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.90
|
| Rate for Payer: United Healthcare All Other HMO |
$10.61
|
| Rate for Payer: United Healthcare HMO Rider |
$10.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.68
|
| Rate for Payer: Vantage Medical Group Senior |
$24.68
|
|
|
FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]
|
Facility
|
IP
|
$29.04
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$24.68 |
| Rate for Payer: Adventist Health Commercial |
$5.81
|
| Rate for Payer: Blue Shield of California Commercial |
$21.43
|
| Rate for Payer: Blue Shield of California EPN |
$14.11
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO |
$20.33
|
| Rate for Payer: Cigna of CA PPO |
$20.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.62
|
| Rate for Payer: EPIC Health Plan Senior |
$11.62
|
| Rate for Payer: Galaxy Health WC |
$24.68
|
| Rate for Payer: Global Benefits Group Commercial |
$17.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$23.23
|
| Rate for Payer: Networks By Design Commercial |
$14.52
|
| Rate for Payer: Prime Health Services Commercial |
$24.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.90
|
| Rate for Payer: United Healthcare All Other HMO |
$10.61
|
| Rate for Payer: United Healthcare HMO Rider |
$10.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.51
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 0173-0696-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.91
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna of CA HMO |
$2.74
|
| Rate for Payer: Cigna of CA PPO |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: EPIC Health Plan Senior |
$1.57
|
| Rate for Payer: Galaxy Health WC |
$3.33
|
| Rate for Payer: Global Benefits Group Commercial |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$3.14
|
| Rate for Payer: Networks By Design Commercial |
$2.55
|
| Rate for Payer: Prime Health Services Commercial |
$3.33
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 0173-0696-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.41
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna of CA HMO |
$2.74
|
| Rate for Payer: Cigna of CA PPO |
$2.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: EPIC Health Plan Senior |
$1.57
|
| Rate for Payer: Galaxy Health WC |
$3.33
|
| Rate for Payer: Global Benefits Group Commercial |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$3.14
|
| Rate for Payer: Networks By Design Commercial |
$2.55
|
| Rate for Payer: Prime Health Services Commercial |
$3.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.96
|
| Rate for Payer: United Healthcare All Other HMO |
$1.96
|
| Rate for Payer: United Healthcare HMO Rider |
$1.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.33
|
| Rate for Payer: Vantage Medical Group Senior |
$3.33
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 0173-0697-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.25
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO |
$3.71
|
| Rate for Payer: Cigna of CA PPO |
$3.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.50
|
| Rate for Payer: Global Benefits Group Commercial |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.71
|
| Rate for Payer: Multiplan Commercial |
$4.24
|
| Rate for Payer: Networks By Design Commercial |
$3.44
|
| Rate for Payer: Prime Health Services Commercial |
$4.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO |
$2.65
|
| Rate for Payer: United Healthcare HMO Rider |
$2.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.50
|
| Rate for Payer: Vantage Medical Group Senior |
$4.50
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 0173-0697-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.91
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO |
$3.71
|
| Rate for Payer: Cigna of CA PPO |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.50
|
| Rate for Payer: Global Benefits Group Commercial |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$4.24
|
| Rate for Payer: Networks By Design Commercial |
$3.44
|
| Rate for Payer: Prime Health Services Commercial |
$4.50
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.15
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other HMO |
$0.68
|
| Rate for Payer: United Healthcare HMO Rider |
$0.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
|
|
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [246638]
|
Facility
|
IP
|
$47.37
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.47 |
| Max. Negotiated Rate |
$40.26 |
| Rate for Payer: Adventist Health Commercial |
$9.47
|
| Rate for Payer: Blue Shield of California Commercial |
$34.96
|
| Rate for Payer: Blue Shield of California EPN |
$23.02
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cigna of CA HMO |
$33.16
|
| Rate for Payer: Cigna of CA PPO |
$33.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.95
|
| Rate for Payer: EPIC Health Plan Senior |
$18.95
|
| Rate for Payer: Galaxy Health WC |
$40.26
|
| Rate for Payer: Global Benefits Group Commercial |
$28.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.37
|
| Rate for Payer: Multiplan Commercial |
$37.90
|
| Rate for Payer: Networks By Design Commercial |
$23.68
|
| Rate for Payer: Prime Health Services Commercial |
$40.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.78
|
| Rate for Payer: United Healthcare All Other HMO |
$17.30
|
| Rate for Payer: United Healthcare HMO Rider |
$16.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.51
|
|
|
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [246638]
|
Facility
|
OP
|
$47.37
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.47 |
| Max. Negotiated Rate |
$53.26 |
| Rate for Payer: Adventist Health Commercial |
$9.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$31.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.26
|
| Rate for Payer: Blue Shield of California Commercial |
$23.53
|
| Rate for Payer: Blue Shield of California EPN |
$23.53
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cigna of CA HMO |
$33.16
|
| Rate for Payer: Cigna of CA PPO |
$33.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.95
|
| Rate for Payer: EPIC Health Plan Senior |
$18.95
|
| Rate for Payer: Galaxy Health WC |
$40.26
|
| Rate for Payer: Global Benefits Group Commercial |
$28.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.16
|
| Rate for Payer: Multiplan Commercial |
$37.90
|
| Rate for Payer: Networks By Design Commercial |
$23.68
|
| Rate for Payer: Prime Health Services Commercial |
$40.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.78
|
| Rate for Payer: United Healthcare All Other HMO |
$17.30
|
| Rate for Payer: United Healthcare HMO Rider |
$16.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.26
|
| Rate for Payer: Vantage Medical Group Senior |
$40.26
|
|
|
FLU VACCINE TV2025(9 YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE [246640]
|
Facility
|
OP
|
$188.21
|
|
|
Service Code
|
HCPCS 90673
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.64 |
| Max. Negotiated Rate |
$198.96 |
| Rate for Payer: Adventist Health Commercial |
$37.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$123.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$159.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$141.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.96
|
| Rate for Payer: Blue Shield of California Commercial |
$87.89
|
| Rate for Payer: Blue Shield of California EPN |
$87.89
|
| Rate for Payer: Cash Price |
$103.52
|
| Rate for Payer: Cash Price |
$103.52
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: Cigna of CA HMO |
$131.75
|
| Rate for Payer: Cigna of CA PPO |
$131.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$159.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$159.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$159.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.28
|
| Rate for Payer: EPIC Health Plan Senior |
$75.28
|
| Rate for Payer: Galaxy Health WC |
$159.98
|
| Rate for Payer: Global Benefits Group Commercial |
$112.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$125.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$167.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$116.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$131.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$131.75
|
| Rate for Payer: Multiplan Commercial |
$150.57
|
| Rate for Payer: Networks By Design Commercial |
$94.11
|
| Rate for Payer: Prime Health Services Commercial |
$159.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$112.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$112.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$70.64
|
| Rate for Payer: United Healthcare All Other HMO |
$68.75
|
| Rate for Payer: United Healthcare HMO Rider |
$67.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$61.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$159.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$159.98
|
| Rate for Payer: Vantage Medical Group Senior |
$159.98
|
|
|
FLU VACCINE TV2025(9 YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE [246640]
|
Facility
|
IP
|
$188.21
|
|
|
Service Code
|
HCPCS 90673
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.64 |
| Max. Negotiated Rate |
$159.98 |
| Rate for Payer: Cigna of CA HMO |
$131.75
|
| Rate for Payer: Cigna of CA PPO |
$131.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.28
|
| Rate for Payer: EPIC Health Plan Senior |
$75.28
|
| Rate for Payer: Galaxy Health WC |
$159.98
|
| Rate for Payer: Global Benefits Group Commercial |
$112.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$125.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$116.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.17
|
| Rate for Payer: Multiplan Commercial |
$150.57
|
| Rate for Payer: Networks By Design Commercial |
$94.11
|
| Rate for Payer: Prime Health Services Commercial |
$159.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$70.64
|
| Rate for Payer: United Healthcare All Other HMO |
$68.75
|
| Rate for Payer: United Healthcare HMO Rider |
$67.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$61.64
|
| Rate for Payer: Adventist Health Commercial |
$37.64
|
| Rate for Payer: Blue Shield of California Commercial |
$138.90
|
| Rate for Payer: Blue Shield of California EPN |
$91.47
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: Cash Price |
$103.52
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
OP
|
$9.71
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.96
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna of CA HMO |
$6.80
|
| Rate for Payer: Cigna of CA PPO |
$6.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.88
|
| Rate for Payer: EPIC Health Plan Senior |
$3.88
|
| Rate for Payer: Galaxy Health WC |
$8.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.80
|
| Rate for Payer: Multiplan Commercial |
$7.77
|
| Rate for Payer: Networks By Design Commercial |
$6.31
|
| Rate for Payer: Prime Health Services Commercial |
$8.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Other HMO |
$4.86
|
| Rate for Payer: United Healthcare HMO Rider |
$4.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.25
|
| Rate for Payer: Vantage Medical Group Senior |
$8.25
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
IP
|
$9.71
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$7.17
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna of CA HMO |
$6.80
|
| Rate for Payer: Cigna of CA PPO |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.88
|
| Rate for Payer: EPIC Health Plan Senior |
$3.88
|
| Rate for Payer: Galaxy Health WC |
$8.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$7.77
|
| Rate for Payer: Networks By Design Commercial |
$6.31
|
| Rate for Payer: Prime Health Services Commercial |
$8.25
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
