|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Senior |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 60432-264-15
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| 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
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
1744080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [238760]
|
Facility
|
IP
|
$45.55
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
NDG238760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$34.16 |
| Rate for Payer: Adventist Health Commercial |
$9.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.29
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.84
|
| Rate for Payer: Heritage Provider Network Senior |
$30.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.39
|
| Rate for Payer: Multiplan Commercial |
$34.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.22
|
|
|
FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [238760]
|
Facility
|
OP
|
$45.55
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
NDG238760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$54.36 |
| Rate for Payer: Adventist Health Commercial |
$9.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.29
|
| Rate for Payer: Blue Shield of California Commercial |
$19.25
|
| Rate for Payer: Blue Shield of California EPN |
$19.25
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.72
|
| Rate for Payer: Dignity Health Senior |
$38.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.09
|
| Rate for Payer: Heritage Provider Network Senior |
$21.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.39
|
| Rate for Payer: Multiplan Commercial |
$34.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.22
|
| Rate for Payer: TriValley Medical Group Senior |
$18.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.72
|
| Rate for Payer: Vantage Medical Group Senior |
$38.72
|
|
|
FLU VACCINE QV2023(18YR UP)RCMB(PF)180 MCG(45 MCGX4)/0.5 ML IM SYRINGE [238762]
|
Facility
|
IP
|
$153.02
|
|
|
Service Code
|
CPT 90682
|
| Hospital Charge Code |
RX238762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.70 |
| Max. Negotiated Rate |
$114.76 |
| Rate for Payer: Adventist Health Commercial |
$30.60
|
| Rate for Payer: Adventist Health Commercial |
$30.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.12
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.59
|
| Rate for Payer: Heritage Provider Network Senior |
$103.60
|
| Rate for Payer: Heritage Provider Network Senior |
$103.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.26
|
| Rate for Payer: Multiplan Commercial |
$114.76
|
| Rate for Payer: Multiplan Commercial |
$114.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.13
|
|
|
FLU VACCINE QV2023(18YR UP)RCMB(PF)180 MCG(45 MCGX4)/0.5 ML IM SYRINGE [238762]
|
Facility
|
OP
|
$153.02
|
|
|
Service Code
|
CPT 90682
|
| Hospital Charge Code |
RX238762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.70 |
| Max. Negotiated Rate |
$178.53 |
| Rate for Payer: Adventist Health Commercial |
$30.60
|
| Rate for Payer: Adventist Health Commercial |
$30.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$130.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$130.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$84.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$84.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$114.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$114.77
|
| Rate for Payer: Blue Shield of California Commercial |
$62.58
|
| Rate for Payer: Blue Shield of California Commercial |
$62.58
|
| Rate for Payer: Blue Shield of California EPN |
$62.58
|
| Rate for Payer: Blue Shield of California EPN |
$62.58
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$130.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$130.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$130.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$130.07
|
| Rate for Payer: Dignity Health Senior |
$130.07
|
| Rate for Payer: Dignity Health Senior |
$130.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.85
|
| Rate for Payer: Heritage Provider Network Senior |
$70.85
|
| Rate for Payer: Heritage Provider Network Senior |
$70.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$121.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$121.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$73.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$73.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.26
|
| Rate for Payer: Multiplan Commercial |
$114.76
|
| Rate for Payer: Multiplan Commercial |
$114.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$61.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$61.21
|
| Rate for Payer: TriValley Medical Group Senior |
$61.21
|
| Rate for Payer: TriValley Medical Group Senior |
$61.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$130.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$130.08
|
| Rate for Payer: Vantage Medical Group Senior |
$130.07
|
| Rate for Payer: Vantage Medical Group Senior |
$130.08
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
1714009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
1714009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| 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
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| 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
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-20
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| 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
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| 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
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
1714008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
OP
|
$9.72
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
ERX91129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.29
|
| Rate for Payer: Blue Shield of California Commercial |
$6.04
|
| Rate for Payer: Blue Shield of California EPN |
$5.71
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.26
|
| Rate for Payer: Dignity Health Senior |
$8.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Senior |
$6.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.89
|
| Rate for Payer: TriValley Medical Group Senior |
$3.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.26
|
| Rate for Payer: Vantage Medical Group Senior |
$8.26
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
IP
|
$9.72
|
|
|
Service Code
|
NDC 10370-176-11
|
| Hospital Charge Code |
ERX91129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.68
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.58
|
| Rate for Payer: Heritage Provider Network Senior |
$6.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.29
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-11
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 53746-361-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| 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 |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| 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 |
$0.05
|
| 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 |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 53746-361-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$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 |
$0.05
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-11
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687-681-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 11534-165-01
|
| Hospital Charge Code |
1710248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| 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 |
$0.05
|
|
