|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
IP
|
$10.36
|
|
|
Service Code
|
NDC 0173-0697-00
|
| Hospital Charge Code |
1744101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Blue Shield of California Commercial |
$7.38
|
| Rate for Payer: Blue Shield of California EPN |
$5.30
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$7.25
|
| Rate for Payer: Cigna of CA PPO |
$7.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: Galaxy Health WC |
$8.81
|
| Rate for Payer: Global Benefits Group Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$8.29
|
| Rate for Payer: Networks By Design Commercial |
$6.73
|
| Rate for Payer: Prime Health Services Commercial |
$8.81
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]
|
Facility
IP
|
$27.38
|
|
|
Service Code
|
NDC 0173-0719-20
|
| Hospital Charge Code |
NDG40698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Blue Shield of California Commercial |
$19.49
|
| Rate for Payer: Blue Shield of California EPN |
$14.02
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Cigna of CA HMO |
$19.17
|
| Rate for Payer: Cigna of CA PPO |
$19.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.95
|
| Rate for Payer: Galaxy Health WC |
$23.27
|
| Rate for Payer: Global Benefits Group Commercial |
$16.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.57
|
| Rate for Payer: Multiplan Commercial |
$21.90
|
| Rate for Payer: Networks By Design Commercial |
$17.80
|
| Rate for Payer: Prime Health Services Commercial |
$23.27
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]
|
Facility
OP
|
$27.38
|
|
|
Service Code
|
NDC 0173-0719-20
|
| Hospital Charge Code |
NDG40698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.31
|
| Rate for Payer: BCBS Transplant Transplant |
$16.43
|
| Rate for Payer: Blue Shield of California Commercial |
$20.18
|
| Rate for Payer: Blue Shield of California EPN |
$15.99
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Cigna of CA HMO |
$19.17
|
| Rate for Payer: Cigna of CA PPO |
$19.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.27
|
| Rate for Payer: Dignity Health Media |
$23.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.95
|
| Rate for Payer: Galaxy Health WC |
$23.27
|
| Rate for Payer: Global Benefits Group Commercial |
$16.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.57
|
| Rate for Payer: Multiplan Commercial |
$21.90
|
| Rate for Payer: Networks By Design Commercial |
$17.80
|
| Rate for Payer: Prime Health Services Commercial |
$23.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$16.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.69
|
| Rate for Payer: United Healthcare All Other HMO |
$13.69
|
| Rate for Payer: United Healthcare HMO Rider |
$13.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.27
|
| Rate for Payer: Vantage Medical Group Senior |
$23.27
|
|
|
FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER [40699]
|
Facility
IP
|
$42.53
|
|
|
Service Code
|
NDC 0173-0720-20
|
| Hospital Charge Code |
NDG40699
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$36.15 |
| Rate for Payer: Blue Shield of California Commercial |
$30.28
|
| Rate for Payer: Blue Shield of California EPN |
$21.78
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: Cigna of CA HMO |
$29.77
|
| Rate for Payer: Cigna of CA PPO |
$29.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.01
|
| Rate for Payer: Galaxy Health WC |
$36.15
|
| Rate for Payer: Global Benefits Group Commercial |
$25.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.21
|
| Rate for Payer: Multiplan Commercial |
$34.02
|
| Rate for Payer: Networks By Design Commercial |
$27.64
|
| Rate for Payer: Prime Health Services Commercial |
$36.15
|
|
|
FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER [40699]
|
Facility
OP
|
$42.53
|
|
|
Service Code
|
NDC 0173-0720-20
|
| Hospital Charge Code |
NDG40699
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$36.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$36.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.34
|
| Rate for Payer: BCBS Transplant Transplant |
$25.52
|
| Rate for Payer: Blue Shield of California Commercial |
$31.34
|
| Rate for Payer: Blue Shield of California EPN |
$24.84
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: Cigna of CA HMO |
$29.77
|
| Rate for Payer: Cigna of CA PPO |
$29.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.15
|
| Rate for Payer: Dignity Health Media |
$36.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$17.01
|
| Rate for Payer: Galaxy Health WC |
$36.15
|
| Rate for Payer: Global Benefits Group Commercial |
$25.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$31.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.21
|
| Rate for Payer: Multiplan Commercial |
$34.02
|
| Rate for Payer: Networks By Design Commercial |
$27.64
|
| Rate for Payer: Prime Health Services Commercial |
$36.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$25.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.26
|
| Rate for Payer: United Healthcare All Other HMO |
$21.26
|
| Rate for Payer: United Healthcare HMO Rider |
$21.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.15
|
| Rate for Payer: Vantage Medical Group Senior |
$36.15
|
|
|
FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER [40697]
|
Facility
IP
|
$23.16
|
|
|
Service Code
|
NDC 0173-0718-20
|
| Hospital Charge Code |
NDG40697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Blue Shield of California Commercial |
$16.49
|
| Rate for Payer: Blue Shield of California EPN |
$11.86
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cigna of CA HMO |
$16.21
|
| Rate for Payer: Cigna of CA PPO |
$16.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.26
|
| Rate for Payer: Galaxy Health WC |
$19.69
|
| Rate for Payer: Global Benefits Group Commercial |
$13.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.56
|
| Rate for Payer: Multiplan Commercial |
$18.53
|
| Rate for Payer: Networks By Design Commercial |
$15.05
|
| Rate for Payer: Prime Health Services Commercial |
$19.69
|
|
|
FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER [40697]
|
Facility
OP
|
$23.16
|
|
|
Service Code
|
NDC 0173-0718-20
|
| Hospital Charge Code |
NDG40697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.80
|
| Rate for Payer: BCBS Transplant Transplant |
$13.90
|
| Rate for Payer: Blue Shield of California Commercial |
$17.07
|
| Rate for Payer: Blue Shield of California EPN |
$13.53
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cigna of CA HMO |
$16.21
|
| Rate for Payer: Cigna of CA PPO |
$16.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.69
|
| Rate for Payer: Dignity Health Media |
$19.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.26
|
| Rate for Payer: Galaxy Health WC |
$19.69
|
| Rate for Payer: Global Benefits Group Commercial |
$13.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$17.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.56
|
| Rate for Payer: Multiplan Commercial |
$18.53
|
| Rate for Payer: Networks By Design Commercial |
$15.05
|
| Rate for Payer: Prime Health Services Commercial |
$19.69
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.58
|
| Rate for Payer: United Healthcare All Other HMO |
$11.58
|
| Rate for Payer: United Healthcare HMO Rider |
$11.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Vantage Medical Group Senior |
$19.69
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
OP
|
$0.83
|
|
|
Service Code
|
NDC 60432-264-15
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.49
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| 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 |
$0.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.33
|
| 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 Transplant Other |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| 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 |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.50
|
| 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
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
IP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.61
|
| 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: 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: 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
IP
|
$0.83
|
|
|
Service Code
|
NDC 60432-264-15
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| 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 |
$0.55
|
| 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 |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
OP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: BCBS Transplant Transplant |
$0.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.61
|
| 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 Media |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.01
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.81
|
| 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 QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [238760]
|
Facility
IP
|
$45.55
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
NDG238760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$38.72 |
| Rate for Payer: Blue Shield of California Commercial |
$32.43
|
| Rate for Payer: Blue Shield of California EPN |
$23.32
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cigna of CA HMO |
$31.88
|
| Rate for Payer: Cigna of CA PPO |
$31.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.22
|
| Rate for Payer: Galaxy Health WC |
$38.72
|
| Rate for Payer: Global Benefits Group Commercial |
$27.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.93
|
| Rate for Payer: Multiplan Commercial |
$36.44
|
| Rate for Payer: Networks By Design Commercial |
$22.78
|
| Rate for Payer: Prime Health Services Commercial |
$38.72
|
|
|
FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [238760]
|
Facility
OP
|
$45.55
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
NDG238760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$155.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$155.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$38.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.19
|
| Rate for Payer: BCBS Transplant Transplant |
$27.33
|
| Rate for Payer: Blue Shield of California Commercial |
$33.57
|
| Rate for Payer: Blue Shield of California EPN |
$20.61
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cigna of CA HMO |
$31.88
|
| Rate for Payer: Cigna of CA PPO |
$31.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.72
|
| Rate for Payer: Dignity Health Media |
$38.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.22
|
| Rate for Payer: Galaxy Health WC |
$38.72
|
| Rate for Payer: Global Benefits Group Commercial |
$27.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$34.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.93
|
| Rate for Payer: Multiplan Commercial |
$36.44
|
| Rate for Payer: Networks By Design Commercial |
$22.78
|
| Rate for Payer: Prime Health Services Commercial |
$38.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.78
|
| Rate for Payer: United Healthcare All Other HMO |
$22.78
|
| Rate for Payer: United Healthcare HMO Rider |
$22.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.72
|
| Rate for Payer: Vantage Medical Group Senior |
$38.72
|
|
|
FLU VACCINE QV2023(18YR UP)RCMB(PF)180 MCG(45 MCGX4)/0.5 ML IM SYRINGE [238762]
|
Facility
OP
|
$153.02
|
|
|
Service Code
|
CPT 90682
|
| Hospital Charge Code |
RX238762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.72 |
| Max. Negotiated Rate |
$510.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$510.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$510.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$130.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$130.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$84.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$84.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$84.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$84.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.18
|
| Rate for Payer: BCBS Transplant Transplant |
$91.82
|
| Rate for Payer: BCBS Transplant Transplant |
$91.81
|
| Rate for Payer: Blue Shield of California Commercial |
$112.78
|
| Rate for Payer: Blue Shield of California Commercial |
$112.78
|
| Rate for Payer: Blue Shield of California EPN |
$64.19
|
| Rate for Payer: Blue Shield of California EPN |
$64.19
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cigna of CA HMO |
$107.11
|
| Rate for Payer: Cigna of CA HMO |
$107.12
|
| Rate for Payer: Cigna of CA PPO |
$107.11
|
| Rate for Payer: Cigna of CA PPO |
$107.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$130.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$130.07
|
| Rate for Payer: Dignity Health Media |
$130.07
|
| Rate for Payer: Dignity Health Media |
$130.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$130.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$130.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$61.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$61.21
|
| Rate for Payer: Galaxy Health WC |
$130.07
|
| Rate for Payer: Galaxy Health WC |
$130.08
|
| Rate for Payer: Global Benefits Group Commercial |
$91.82
|
| Rate for Payer: Global Benefits Group Commercial |
$91.81
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$114.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$114.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$102.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$102.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$147.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$147.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.72
|
| Rate for Payer: Multiplan Commercial |
$122.42
|
| Rate for Payer: Multiplan Commercial |
$122.42
|
| Rate for Payer: Networks By Design Commercial |
$76.52
|
| Rate for Payer: Networks By Design Commercial |
$76.51
|
| Rate for Payer: Prime Health Services Commercial |
$130.07
|
| Rate for Payer: Prime Health Services Commercial |
$130.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$91.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$91.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$91.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$91.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$76.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$76.52
|
| Rate for Payer: United Healthcare All Other HMO |
$76.51
|
| Rate for Payer: United Healthcare All Other HMO |
$76.52
|
| Rate for Payer: United Healthcare HMO Rider |
$76.52
|
| Rate for Payer: United Healthcare HMO Rider |
$76.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$76.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$76.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$130.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$130.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$130.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$130.08
|
| Rate for Payer: Vantage Medical Group Senior |
$130.07
|
| Rate for Payer: Vantage Medical Group Senior |
$130.08
|
|
|
FLU VACCINE QV2023(18YR UP)RCMB(PF)180 MCG(45 MCGX4)/0.5 ML IM SYRINGE [238762]
|
Facility
IP
|
$153.03
|
|
|
Service Code
|
CPT 90682
|
| Hospital Charge Code |
RX238762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.73 |
| Max. Negotiated Rate |
$130.08 |
| Rate for Payer: Blue Shield of California Commercial |
$108.96
|
| Rate for Payer: Blue Shield of California Commercial |
$108.95
|
| Rate for Payer: Blue Shield of California EPN |
$78.35
|
| Rate for Payer: Blue Shield of California EPN |
$78.35
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cigna of CA HMO |
$107.12
|
| Rate for Payer: Cigna of CA HMO |
$107.11
|
| Rate for Payer: Cigna of CA PPO |
$107.12
|
| Rate for Payer: Cigna of CA PPO |
$107.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$61.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$61.21
|
| Rate for Payer: Galaxy Health WC |
$130.07
|
| Rate for Payer: Galaxy Health WC |
$130.08
|
| Rate for Payer: Global Benefits Group Commercial |
$91.81
|
| Rate for Payer: Global Benefits Group Commercial |
$91.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$102.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$102.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.72
|
| Rate for Payer: Multiplan Commercial |
$122.42
|
| Rate for Payer: Multiplan Commercial |
$122.42
|
| Rate for Payer: Networks By Design Commercial |
$76.52
|
| Rate for Payer: Networks By Design Commercial |
$76.51
|
| Rate for Payer: Prime Health Services Commercial |
$130.07
|
| Rate for Payer: Prime Health Services Commercial |
$130.08
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
OP
|
$0.71
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
1714009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: BCBS Transplant Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 |
$0.60
|
| Rate for Payer: Dignity Health Media |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.53
|
| 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: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.43
|
| 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 |
$0.60
|
| 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
|
$0.71
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
1714009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| 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: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: BCBS Transplant Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 Media |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.54
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.43
|
| 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
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: BCBS Transplant Transplant |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| 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: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Media |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.45
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.36
|
| 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
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
1714008
|
|
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
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
1714008
|
|
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
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: BCBS Transplant Transplant |
$0.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| 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: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Media |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.45
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.36
|
| 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
IP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| 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: 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: 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 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 |
$2.33 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Blue Shield of California Commercial |
$6.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.98
|
| Rate for Payer: Cash Price |
$4.37
|
| 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 |
$3.89
|
| Rate for Payer: Galaxy Health WC |
$8.26
|
| 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: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$7.78
|
| Rate for Payer: Networks By Design Commercial |
$6.32
|
| Rate for Payer: Prime Health Services Commercial |
$8.26
|
|
|
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 |
$2.33 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.79
|
| Rate for Payer: BCBS Transplant Transplant |
$5.83
|
| Rate for Payer: Blue Shield of California Commercial |
$7.16
|
| Rate for Payer: Blue Shield of California EPN |
$5.68
|
| Rate for Payer: Cash Price |
$4.37
|
| 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 |
$8.26
|
| Rate for Payer: Dignity Health Media |
$8.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.89
|
| Rate for Payer: Galaxy Health WC |
$8.26
|
| Rate for Payer: Global Benefits Group Commercial |
$5.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.29
|
| 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: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$7.78
|
| Rate for Payer: Networks By Design Commercial |
$6.32
|
| Rate for Payer: Prime Health Services Commercial |
$8.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.83
|
| 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 |
$8.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.26
|
| Rate for Payer: Vantage Medical Group Senior |
$8.26
|
|
