|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 65862-621-01
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Blue Distinction Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 0054-0010-25
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Distinction Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Media |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| 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 |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 0054-0010-20
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 62559-380-01
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 0054-0010-21
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 0054-0010-25
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 0054-0010-21
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Distinction Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Media |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| 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 |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 65862-621-01
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 0054-0010-20
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Distinction Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Media |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| 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 |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
FLECAINIDE 50 MG TABLET [10043]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 62559-380-01
|
| Hospital Charge Code |
1711525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
FLECAINIDE ORAL SUSPENSION COMPOUND 20 MG/ML [4080273]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 9994-0802-73
|
| Hospital Charge Code |
1715085
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
FLECAINIDE ORAL SUSPENSION COMPOUND 20 MG/ML [4080273]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 9994-0802-73
|
| Hospital Charge Code |
1715085
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.33
|
| Rate for Payer: Blue Distinction Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Media |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
FLORBETABEN F-18 8.1 MCI (300 MBQ) INTRAVENOUS SOLUTION [231724]
|
Facility
|
IP
|
$3,360.00
|
|
|
Service Code
|
CPT Q9983
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$806.40 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Blue Shield of California Commercial |
$2,392.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,720.32
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,344.00
|
| Rate for Payer: Galaxy Health WC |
$2,856.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,016.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,241.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,280.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$806.40
|
| Rate for Payer: Multiplan Commercial |
$2,688.00
|
| Rate for Payer: Networks By Design Commercial |
$2,184.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,268.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1,239.17
|
| Rate for Payer: United Healthcare HMO Rider |
$1,212.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,108.80
|
|
|
FLORBETABEN F-18 8.1 MCI (300 MBQ) INTRAVENOUS SOLUTION [231724]
|
Facility
|
OP
|
$3,360.00
|
|
|
Service Code
|
CPT Q9983
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$806.40 |
| Max. Negotiated Rate |
$5,320.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,856.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,848.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,848.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,989.39
|
| Rate for Payer: Blue Distinction Transplant |
$2,016.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,985.76
|
| Rate for Payer: Blue Shield of California EPN |
$1,575.84
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna of CA HMO |
$2,150.40
|
| Rate for Payer: Cigna of CA PPO |
$2,486.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,856.00
|
| Rate for Payer: Dignity Health Media |
$2,856.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,856.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,344.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,344.00
|
| Rate for Payer: Galaxy Health WC |
$2,856.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,016.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,520.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,241.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,320.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$806.40
|
| Rate for Payer: Multiplan Commercial |
$2,688.00
|
| Rate for Payer: Networks By Design Commercial |
$2,184.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,856.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,016.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,016.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,680.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,680.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,680.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,856.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,856.00
|
| Rate for Payer: Vantage Medical Group Senior |
$2,856.00
|
|
|
FLORBETAPIR F-18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [196481]
|
Facility
|
IP
|
$342.12
|
|
|
Service Code
|
CPT A9586
|
| Hospital Charge Code |
ERX196481
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$82.11 |
| Max. Negotiated Rate |
$290.80 |
| Rate for Payer: Blue Shield of California Commercial |
$243.59
|
| Rate for Payer: Blue Shield of California EPN |
$175.17
|
| Rate for Payer: Cash Price |
$153.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.85
|
| Rate for Payer: Galaxy Health WC |
$290.80
|
| Rate for Payer: Global Benefits Group Commercial |
$205.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.11
|
| Rate for Payer: Multiplan Commercial |
$273.70
|
| Rate for Payer: Networks By Design Commercial |
$222.38
|
| Rate for Payer: Prime Health Services Commercial |
$290.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$129.18
|
| Rate for Payer: United Healthcare All Other HMO |
$126.17
|
| Rate for Payer: United Healthcare HMO Rider |
$123.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$112.90
|
|
|
FLORBETAPIR F-18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [196481]
|
Facility
|
OP
|
$342.12
|
|
|
Service Code
|
CPT A9586
|
| Hospital Charge Code |
ERX196481
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$82.11 |
| Max. Negotiated Rate |
$3,410.38 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$290.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$188.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,410.38
|
| Rate for Payer: Blue Distinction Transplant |
$205.27
|
| Rate for Payer: Blue Shield of California Commercial |
$202.19
|
| Rate for Payer: Blue Shield of California EPN |
$160.45
|
| Rate for Payer: Cash Price |
$153.95
|
| Rate for Payer: Cash Price |
$153.95
|
| Rate for Payer: Cigna of CA HMO |
$218.96
|
| Rate for Payer: Cigna of CA PPO |
$253.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$290.80
|
| Rate for Payer: Dignity Health Media |
$290.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$290.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$136.85
|
| Rate for Payer: Galaxy Health WC |
$290.80
|
| Rate for Payer: Global Benefits Group Commercial |
$205.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$256.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.11
|
| Rate for Payer: Multiplan Commercial |
$273.70
|
| Rate for Payer: Networks By Design Commercial |
$222.38
|
| Rate for Payer: Prime Health Services Commercial |
$290.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.06
|
| Rate for Payer: United Healthcare All Other HMO |
$171.06
|
| Rate for Payer: United Healthcare HMO Rider |
$171.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$290.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$290.80
|
| Rate for Payer: Vantage Medical Group Senior |
$290.80
|
|
|
FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [219653]
|
Facility
|
OP
|
$5,760.00
|
|
|
Service Code
|
CPT A9588
|
| Hospital Charge Code |
ERX219653
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$783.32 |
| Max. Negotiated Rate |
$4,896.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,896.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,168.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,168.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$783.32
|
| Rate for Payer: Blue Distinction Transplant |
$3,456.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,404.16
|
| Rate for Payer: Blue Shield of California EPN |
$2,701.44
|
| Rate for Payer: Cash Price |
$2,592.00
|
| Rate for Payer: Cash Price |
$2,592.00
|
| Rate for Payer: Cigna of CA HMO |
$3,686.40
|
| Rate for Payer: Cigna of CA PPO |
$4,262.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,896.00
|
| Rate for Payer: Dignity Health Media |
$4,896.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,896.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,304.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,304.00
|
| Rate for Payer: Galaxy Health WC |
$4,896.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,456.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4,320.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,841.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,382.40
|
| Rate for Payer: Multiplan Commercial |
$4,608.00
|
| Rate for Payer: Networks By Design Commercial |
$3,744.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,896.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,456.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,456.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,880.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,880.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,880.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,896.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,896.00
|
| Rate for Payer: Vantage Medical Group Senior |
$4,896.00
|
|
|
FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [219653]
|
Facility
|
IP
|
$5,760.00
|
|
|
Service Code
|
CPT A9588
|
| Hospital Charge Code |
ERX219653
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,382.40 |
| Max. Negotiated Rate |
$4,896.00 |
| Rate for Payer: Blue Shield of California Commercial |
$4,101.12
|
| Rate for Payer: Blue Shield of California EPN |
$2,949.12
|
| Rate for Payer: Cash Price |
$2,592.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,304.00
|
| Rate for Payer: Galaxy Health WC |
$4,896.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,456.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,841.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,194.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,382.40
|
| Rate for Payer: Multiplan Commercial |
$4,608.00
|
| Rate for Payer: Networks By Design Commercial |
$3,744.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,896.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,174.98
|
| Rate for Payer: United Healthcare All Other HMO |
$2,124.29
|
| Rate for Payer: United Healthcare HMO Rider |
$2,078.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,900.80
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 70710-1138-3
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 67405-602-03
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 68001-252-04
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.43
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.52
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 67405-602-03
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 68001-252-04
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.07
|
| Rate for Payer: Blue Distinction Transplant |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.52
|
| Rate for Payer: Dignity Health Media |
$1.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.43
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Vantage Medical Group Senior |
$1.52
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 70710-1138-3
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
FLUCONAZOLE 100 MG TABLET [10044]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 57237-004-30
|
| Hospital Charge Code |
1711488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| 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: 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: 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
|
|
