|
FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10050]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
CPT J1450
|
| Hospital Charge Code |
1753160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
|
|
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 57237-150-35
|
| Hospital Charge Code |
1715300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
| Rate for Payer: Dignity Health Senior |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Senior |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 0049-3450-19
|
| Hospital Charge Code |
1715300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 59762-5030-1
|
| Hospital Charge Code |
1715300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.19
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$0.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]
|
Facility
|
IP
|
$1.37
|
|
|
Service Code
|
NDC 57237-150-35
|
| Hospital Charge Code |
1715300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.94
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
|
|
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 59762-5030-1
|
| Hospital Charge Code |
1715300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
|
|
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 0049-3450-19
|
| Hospital Charge Code |
1715300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Senior |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
FLUCONAZOLE 50 MG TABLET [10046]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 68462-101-30
|
| Hospital Charge Code |
1711487
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
FLUCONAZOLE 50 MG TABLET [10046]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 57237-003-30
|
| Hospital Charge Code |
1711487
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
FLUCONAZOLE 50 MG TABLET [10046]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 62559-990-30
|
| Hospital Charge Code |
1711487
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
FLUCONAZOLE 50 MG TABLET [10046]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 62559-990-30
|
| Hospital Charge Code |
1711487
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
FLUCONAZOLE 50 MG TABLET [10046]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 68462-101-30
|
| Hospital Charge Code |
1711487
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
FLUCONAZOLE 50 MG TABLET [10046]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 57237-003-30
|
| Hospital Charge Code |
1711487
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
OP
|
$30.12
|
|
|
Service Code
|
NDC 59651-331-01
|
| Hospital Charge Code |
1710458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.59
|
| Rate for Payer: Blue Shield of California Commercial |
$18.70
|
| Rate for Payer: Blue Shield of California EPN |
$17.68
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.60
|
| Rate for Payer: Dignity Health Senior |
$25.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.64
|
| Rate for Payer: Heritage Provider Network Senior |
$18.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.60
|
| Rate for Payer: Vantage Medical Group Senior |
$25.60
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 42794-009-08
|
| Hospital Charge Code |
1710458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Blue Shield of California Commercial |
$22.36
|
| Rate for Payer: Blue Shield of California EPN |
$21.13
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Senior |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.28
|
| Rate for Payer: Heritage Provider Network Senior |
$22.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.40
|
| Rate for Payer: TriValley Medical Group Senior |
$14.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
IP
|
$30.12
|
|
|
Service Code
|
NDC 59651-331-01
|
| Hospital Charge Code |
1710458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.69
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.39
|
| Rate for Payer: Heritage Provider Network Senior |
$20.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
|
|
FLUCYTOSINE 250 MG CAPSULE [10051]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 42794-009-08
|
| Hospital Charge Code |
1710458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.37
|
| Rate for Payer: Heritage Provider Network Senior |
$24.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 43386-770-01
|
| Hospital Charge Code |
1710466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 42794-010-08
|
| Hospital Charge Code |
1710466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Adventist Health Commercial |
$13.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.72
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.04
|
| Rate for Payer: Heritage Provider Network Senior |
$46.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.00
|
| Rate for Payer: Multiplan Commercial |
$51.00
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 43386-770-01
|
| Hospital Charge Code |
1710466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14.90
|
| Rate for Payer: Blue Shield of California EPN |
$14.09
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Senior |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.86
|
| Rate for Payer: Heritage Provider Network Senior |
$14.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
IP
|
$158.81
|
|
|
Service Code
|
NDC 42494-340-03
|
| Hospital Charge Code |
1710466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.74 |
| Max. Negotiated Rate |
$119.11 |
| Rate for Payer: Adventist Health Commercial |
$31.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$109.10
|
| Rate for Payer: Cash Price |
$71.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$107.51
|
| Rate for Payer: Heritage Provider Network Senior |
$107.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.70
|
| Rate for Payer: Multiplan Commercial |
$119.11
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
NDC 42794-010-08
|
| Hospital Charge Code |
1710466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$57.80 |
| Rate for Payer: Adventist Health Commercial |
$13.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.00
|
| Rate for Payer: Blue Shield of California Commercial |
$42.23
|
| Rate for Payer: Blue Shield of California EPN |
$39.92
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.80
|
| Rate for Payer: Dignity Health Senior |
$57.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.09
|
| Rate for Payer: Heritage Provider Network Senior |
$42.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.00
|
| Rate for Payer: Multiplan Commercial |
$51.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.20
|
| Rate for Payer: TriValley Medical Group Senior |
$27.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.80
|
| Rate for Payer: Vantage Medical Group Senior |
$57.80
|
|
|
FLUCYTOSINE 500 MG CAPSULE [10052]
|
Facility
|
OP
|
$158.81
|
|
|
Service Code
|
NDC 42494-340-03
|
| Hospital Charge Code |
1710466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.74 |
| Max. Negotiated Rate |
$134.99 |
| Rate for Payer: Adventist Health Commercial |
$31.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$84.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$109.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$134.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$87.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$119.11
|
| Rate for Payer: Blue Shield of California Commercial |
$98.62
|
| Rate for Payer: Blue Shield of California EPN |
$93.22
|
| Rate for Payer: Cash Price |
$71.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$134.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$134.99
|
| Rate for Payer: Dignity Health Senior |
$134.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.30
|
| Rate for Payer: Heritage Provider Network Senior |
$98.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$76.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.70
|
| Rate for Payer: Multiplan Commercial |
$119.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$63.52
|
| Rate for Payer: TriValley Medical Group Senior |
$63.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$134.99
|
| Rate for Payer: Vantage Medical Group Senior |
$134.99
|
|
|
FLUCYTOSINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080274]
|
Facility
|
OP
|
$9.38
|
|
|
Service Code
|
NDC 9994-0802-74
|
| Hospital Charge Code |
1715313
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.04
|
| Rate for Payer: Blue Shield of California Commercial |
$5.82
|
| Rate for Payer: Blue Shield of California EPN |
$5.51
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.97
|
| Rate for Payer: Dignity Health Senior |
$7.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.81
|
| Rate for Payer: Heritage Provider Network Senior |
$5.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.75
|
| Rate for Payer: TriValley Medical Group Senior |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.97
|
| Rate for Payer: Vantage Medical Group Senior |
$7.97
|
|
|
FLUCYTOSINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080274]
|
Facility
|
IP
|
$9.38
|
|
|
Service Code
|
NDC 9994-0802-74
|
| Hospital Charge Code |
1715313
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.04 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.44
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.35
|
| Rate for Payer: Heritage Provider Network Senior |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
|
