|
FLUMAZENIL 0.5 MG/5 ML VIAL - CODE [4080567]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 63323-424-05
|
| Hospital Charge Code |
1721033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
FLUOCINOLONE 0.01 % SCALP OIL AND SHOWER CAP [117479]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 68791-102-04
|
| Hospital Charge Code |
1743712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
FLUOCINOLONE 0.01 % SCALP OIL AND SHOWER CAP [117479]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 68791-102-04
|
| Hospital Charge Code |
1743712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
FLUOCINOLONE 0.01 % TOPICAL BODY OIL [10057]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 45802-887-26
|
| Hospital Charge Code |
NDG10057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| 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 Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
FLUOCINOLONE 0.01 % TOPICAL BODY OIL [10057]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 68791-101-04
|
| Hospital Charge Code |
NDG10057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| 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 Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
FLUOCINOLONE 0.01 % TOPICAL BODY OIL [10057]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 45802-887-26
|
| Hospital Charge Code |
NDG10057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
FLUOCINOLONE 0.01 % TOPICAL BODY OIL [10057]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 68791-101-04
|
| Hospital Charge Code |
NDG10057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
FLUOCINOLONE 0.01 % TOPICAL CREAM [3183]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
NDC 0713-0223-60
|
| Hospital Charge Code |
1743169
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.38
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Senior |
$0.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
FLUOCINOLONE 0.01 % TOPICAL CREAM [3183]
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
NDC 52565-031-15
|
| Hospital Charge Code |
1743274
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.04
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Senior |
$2.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.23
|
|
|
FLUOCINOLONE 0.01 % TOPICAL CREAM [3183]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 0713-0223-15
|
| Hospital Charge Code |
1743274
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
FLUOCINOLONE 0.01 % TOPICAL CREAM [3183]
|
Facility
|
OP
|
$2.97
|
|
|
Service Code
|
NDC 52565-031-15
|
| Hospital Charge Code |
1743274
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.74
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Senior |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.84
|
| Rate for Payer: Heritage Provider Network Senior |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.19
|
| Rate for Payer: TriValley Medical Group Senior |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
FLUOCINOLONE 0.01 % TOPICAL CREAM [3183]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
NDC 0713-0223-60
|
| Hospital Charge Code |
1743169
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Senior |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
FLUOCINOLONE 0.01 % TOPICAL CREAM [3183]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 0713-0223-15
|
| Hospital Charge Code |
1743274
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
FLUOCINOLONE 0.01 % TOPICAL SOLUTION [3186]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 52565-012-59
|
| Hospital Charge Code |
1743114
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Senior |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
FLUOCINOLONE 0.01 % TOPICAL SOLUTION [3186]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 52565-012-59
|
| Hospital Charge Code |
1743114
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
NDC 0168-0064-15
|
| Hospital Charge Code |
1743235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.91
|
| Rate for Payer: Dignity Health Senior |
$1.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: Vantage Medical Group Senior |
$1.91
|
|
|
FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
NDC 0713-0224-60
|
| Hospital Charge Code |
1743208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.16
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.27
|
|
|
FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
NDC 0713-0224-60
|
| Hospital Charge Code |
1743208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]
|
Facility
|
OP
|
$2.26
|
|
|
Service Code
|
NDC 0713-0224-15
|
| Hospital Charge Code |
1743235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.92
|
| Rate for Payer: Dignity Health Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.92
|
| Rate for Payer: Vantage Medical Group Senior |
$1.92
|
|
|
FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]
|
Facility
|
IP
|
$2.26
|
|
|
Service Code
|
NDC 0713-0224-15
|
| Hospital Charge Code |
1743235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
NDC 0168-0064-15
|
| Hospital Charge Code |
1743235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
|
|
FLUOCINOLONE 0.18 MG INTRAVITREAL IMPLANT [223628]
|
Facility
|
IP
|
$10,795.20
|
|
|
Service Code
|
CPT J7314
|
| Hospital Charge Code |
ERX223628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,953.93 |
| Max. Negotiated Rate |
$8,096.40 |
| Rate for Payer: Adventist Health Commercial |
$2,159.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,416.30
|
| Rate for Payer: Cash Price |
$4,857.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,965.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,829.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,308.35
|
| Rate for Payer: Heritage Provider Network Senior |
$7,308.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,953.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,698.80
|
| Rate for Payer: Multiplan Commercial |
$8,096.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,935.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,606.68
|
|
|
FLUOCINOLONE 0.18 MG INTRAVITREAL IMPLANT [223628]
|
Facility
|
OP
|
$10,795.20
|
|
|
Service Code
|
CPT J7314
|
| Hospital Charge Code |
ERX223628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$504.22 |
| Max. Negotiated Rate |
$8,096.40 |
| Rate for Payer: Adventist Health Commercial |
$2,159.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,299.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,416.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$661.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$581.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$581.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,023.32
|
| Rate for Payer: Blue Shield of California Commercial |
$504.22
|
| Rate for Payer: Blue Shield of California EPN |
$504.22
|
| Rate for Payer: Cash Price |
$4,857.84
|
| Rate for Payer: Cash Price |
$4,857.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,965.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$793.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$581.90
|
| Rate for Payer: Dignity Health Senior |
$581.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,908.93
|
| Rate for Payer: EPIC Health Plan Medicare |
$529.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,998.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4,998.18
|
| Rate for Payer: Humana Medicare |
$529.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$825.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$529.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,005.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,953.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$624.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,698.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$666.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$666.54
|
| Rate for Payer: Multiplan Commercial |
$8,096.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,318.08
|
| Rate for Payer: TriValley Medical Group Senior |
$4,318.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,935.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,606.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$793.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$581.90
|
| Rate for Payer: Vantage Medical Group Senior |
$529.00
|
|
|
FLUOCINOLONE 0.19 MG INTRAVITREAL IMPLANT [208310]
|
Facility
|
IP
|
$10,560.00
|
|
|
Service Code
|
CPT J7313
|
| Hospital Charge Code |
ERX208310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,911.36 |
| Max. Negotiated Rate |
$7,920.00 |
| Rate for Payer: Adventist Health Commercial |
$2,112.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,254.72
|
| Rate for Payer: Cash Price |
$4,752.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,857.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,702.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,149.12
|
| Rate for Payer: Heritage Provider Network Senior |
$7,149.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,911.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,640.00
|
| Rate for Payer: Multiplan Commercial |
$7,920.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,850.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,528.10
|
|
|
FLUOCINOLONE 0.19 MG INTRAVITREAL IMPLANT [208310]
|
Facility
|
OP
|
$10,560.00
|
|
|
Service Code
|
CPT J7313
|
| Hospital Charge Code |
ERX208310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$472.42 |
| Max. Negotiated Rate |
$7,920.00 |
| Rate for Payer: Adventist Health Commercial |
$2,112.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,206.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,254.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$613.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$540.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$540.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$989.84
|
| Rate for Payer: Blue Shield of California Commercial |
$472.42
|
| Rate for Payer: Blue Shield of California EPN |
$472.42
|
| Rate for Payer: Cash Price |
$4,752.00
|
| Rate for Payer: Cash Price |
$4,752.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,857.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$736.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$540.04
|
| Rate for Payer: Dignity Health Senior |
$540.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,758.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$490.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,889.28
|
| Rate for Payer: Heritage Provider Network Senior |
$4,889.28
|
| Rate for Payer: Humana Medicare |
$490.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$765.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$490.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$932.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,911.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$579.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,640.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$618.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$618.59
|
| Rate for Payer: Multiplan Commercial |
$7,920.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,224.00
|
| Rate for Payer: TriValley Medical Group Senior |
$4,224.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,850.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,528.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$736.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$540.04
|
| Rate for Payer: Vantage Medical Group Senior |
$490.95
|
|
