|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 65862-193-01
|
| Hospital Charge Code |
1711185
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 65862-193-01
|
| Hospital Charge Code |
1711185
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
FLUOXETINE 20 MG TABLET [17463]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 59651-309-30
|
| Hospital Charge Code |
ERX17463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| 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 |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Senior |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| 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 Commercial |
$0.18
|
| 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 |
$0.29
|
| 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 |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
FLUOXETINE 20 MG TABLET [17463]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 59651-309-30
|
| Hospital Charge Code |
ERX17463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| 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 |
$0.29
|
|
|
FLUPHENAZINE 2.5 MG/5 ML ORAL ELIXIR [10072]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0121-0654-02
|
| Hospital Charge Code |
NDG10072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
FLUPHENAZINE 2.5 MG/5 ML ORAL ELIXIR [10072]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0121-0654-02
|
| Hospital Charge Code |
NDG10072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 69238-1679-1
|
| Hospital Charge Code |
1710622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$2.78
|
|
|
Service Code
|
NDC 0527-1789-01
|
| Hospital Charge Code |
1710622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.36
|
| Rate for Payer: Dignity Health Senior |
$2.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Senior |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2.36
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
NDC 69238-1679-1
|
| Hospital Charge Code |
1710622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
IP
|
$2.78
|
|
|
Service Code
|
NDC 0527-1789-01
|
| Hospital Charge Code |
1710622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.91
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]
|
Facility
|
OP
|
$29.04
|
|
|
Service Code
|
CPT J2680
|
| Hospital Charge Code |
1720193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$106.80 |
| Rate for Payer: Adventist Health Commercial |
$5.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.80
|
| Rate for Payer: Blue Shield of California Commercial |
$24.68
|
| Rate for Payer: Blue Shield of California EPN |
$24.68
|
| Rate for Payer: Cash Price |
$13.07
|
| Rate for Payer: Cash Price |
$13.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.68
|
| Rate for Payer: Dignity Health Senior |
$24.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.45
|
| Rate for Payer: Heritage Provider Network Senior |
$13.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: Multiplan Commercial |
$21.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.62
|
| Rate for Payer: TriValley Medical Group Senior |
$11.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.68
|
| Rate for Payer: Vantage Medical Group Senior |
$24.68
|
|
|
FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]
|
Facility
|
IP
|
$29.04
|
|
|
Service Code
|
CPT J2680
|
| Hospital Charge Code |
1720193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$21.78 |
| Rate for Payer: Adventist Health Commercial |
$5.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.95
|
| Rate for Payer: Cash Price |
$13.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.66
|
| Rate for Payer: Heritage Provider Network Senior |
$19.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: Multiplan Commercial |
$21.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.70
|
|
|
FLURAZEPAM 15 MG CAPSULE [3223]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 0378-4415-01
|
| Hospital Charge Code |
1730039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
FLURAZEPAM 15 MG CAPSULE [3223]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0378-4415-01
|
| Hospital Charge Code |
1730039
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
IP
|
$7.88
|
|
|
Service Code
|
NDC 0173-0696-00
|
| Hospital Charge Code |
1744100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.91 |
| Rate for Payer: Adventist Health Commercial |
$1.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.41
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.33
|
| Rate for Payer: Heritage Provider Network Senior |
$5.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$5.91
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
OP
|
$7.88
|
|
|
Service Code
|
NDC 0173-0696-00
|
| Hospital Charge Code |
1744100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Adventist Health Commercial |
$1.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.91
|
| Rate for Payer: Blue Shield of California Commercial |
$4.89
|
| Rate for Payer: Blue Shield of California EPN |
$4.63
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.70
|
| Rate for Payer: Dignity Health Senior |
$6.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.88
|
| Rate for Payer: Heritage Provider Network Senior |
$4.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$5.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Senior |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.70
|
| Rate for Payer: Vantage Medical Group Senior |
$6.70
|
|
|
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 |
$1.88 |
| Max. Negotiated Rate |
$7.77 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.12
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$7.77
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
|
OP
|
$10.36
|
|
|
Service Code
|
NDC 0173-0697-00
|
| Hospital Charge Code |
1744101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.77
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.08
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.81
|
| Rate for Payer: Dignity Health Senior |
$8.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.41
|
| Rate for Payer: Heritage Provider Network Senior |
$6.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$7.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.14
|
| Rate for Payer: TriValley Medical Group Senior |
$4.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.81
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$4.96 |
| Max. Negotiated Rate |
$20.54 |
| Rate for Payer: Adventist Health Commercial |
$5.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.81
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.54
|
| Rate for Payer: Heritage Provider Network Senior |
$18.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.84
|
| Rate for Payer: Multiplan Commercial |
$20.54
|
|
|
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 |
$4.96 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Adventist Health Commercial |
$5.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.54
|
| Rate for Payer: Blue Shield of California Commercial |
$17.00
|
| Rate for Payer: Blue Shield of California EPN |
$16.07
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.27
|
| Rate for Payer: Dignity Health Senior |
$23.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.95
|
| Rate for Payer: Heritage Provider Network Senior |
$16.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.84
|
| Rate for Payer: Multiplan Commercial |
$20.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.95
|
| Rate for Payer: TriValley Medical Group Senior |
$10.95
|
| 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
|
OP
|
$42.53
|
|
|
Service Code
|
NDC 0173-0720-20
|
| Hospital Charge Code |
NDG40699
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$36.15 |
| Rate for Payer: Adventist Health Commercial |
$8.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.90
|
| Rate for Payer: Blue Shield of California Commercial |
$26.41
|
| Rate for Payer: Blue Shield of California EPN |
$24.97
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.15
|
| Rate for Payer: Dignity Health Senior |
$36.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.33
|
| Rate for Payer: Heritage Provider Network Senior |
$26.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.63
|
| Rate for Payer: Multiplan Commercial |
$31.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.01
|
| Rate for Payer: TriValley Medical Group Senior |
$17.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.15
|
| Rate for Payer: Vantage Medical Group Senior |
$36.15
|
|
|
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 |
$7.70 |
| Max. Negotiated Rate |
$31.90 |
| Rate for Payer: Adventist Health Commercial |
$8.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.22
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.79
|
| Rate for Payer: Heritage Provider Network Senior |
$28.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.63
|
| Rate for Payer: Multiplan Commercial |
$31.90
|
|
|
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 |
$4.19 |
| Max. Negotiated Rate |
$17.37 |
| Rate for Payer: Adventist Health Commercial |
$4.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.91
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.68
|
| Rate for Payer: Heritage Provider Network Senior |
$15.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.79
|
| Rate for Payer: Multiplan Commercial |
$17.37
|
|
|
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 |
$4.19 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Adventist Health Commercial |
$4.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.37
|
| Rate for Payer: Blue Shield of California Commercial |
$14.38
|
| Rate for Payer: Blue Shield of California EPN |
$13.59
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: Dignity Health Senior |
$19.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.34
|
| Rate for Payer: Heritage Provider Network Senior |
$14.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.79
|
| Rate for Payer: Multiplan Commercial |
$17.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.26
|
| Rate for Payer: TriValley Medical Group Senior |
$9.26
|
| 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
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 60432-264-15
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
