|
FLUOROURACIL 5 % TOPICAL SOLUTION [10068]
|
Facility
|
IP
|
$9.35
|
|
|
Service Code
|
NDC 51672-4063-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.01 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.33
|
| Rate for Payer: Heritage Provider Network Senior |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
|
|
FLUOROURACIL 5 % TOPICAL SOLUTION [10068]
|
Facility
|
OP
|
$9.35
|
|
|
Service Code
|
NDC 51672-4063-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.95 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.01
|
| Rate for Payer: Blue Shield of California Commercial |
$5.70
|
| Rate for Payer: Blue Shield of California EPN |
$4.56
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.95
|
| Rate for Payer: Dignity Health Senior |
$7.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.79
|
| Rate for Payer: Heritage Provider Network Senior |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.54
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.74
|
| Rate for Payer: TriValley Medical Group Senior |
$3.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.95
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 65862-192-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| 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: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 68001-399-00
|
| Hospital Charge Code |
901700029
|
|
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: 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 |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 68001-399-00
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| 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: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 50111-647-01
|
| Hospital Charge Code |
901700029
|
|
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: 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 |
$0.05
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 50111-647-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| 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: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 65862-192-01
|
| Hospital Charge Code |
901700029
|
|
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: 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 |
$0.05
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 65862-193-01
|
| Hospital Charge Code |
901700029
|
|
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: 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 68001-400-00
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.04
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| 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: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 50111-648-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| 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: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 68001-400-00
|
| Hospital Charge Code |
901700029
|
|
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: 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
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 0904-7346-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0904-7346-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 65862-193-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.04
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| 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: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 50111-648-01
|
| Hospital Charge Code |
901700029
|
|
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: 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 |
$0.05
|
|
|
FLUOXETINE 20 MG TABLET [17463]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 59651-309-30
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.21
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.27
|
| 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: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| 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 |
901700029
|
|
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: Cash Price |
$0.21
|
| 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
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0121-0654-02
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.35
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| 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: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
FLUPHENAZINE 2.5 MG/5 ML ORAL ELIXIR [10072]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0121-0654-02
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.35
|
| 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 TABLET [3220]
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 50268-367-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.25
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$8.89
|
|
|
Service Code
|
NDC 0904-7158-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Adventist Health Commercial |
$1.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.67
|
| Rate for Payer: Blue Shield of California Commercial |
$5.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.34
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.56
|
| Rate for Payer: Dignity Health Senior |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.50
|
| Rate for Payer: Heritage Provider Network Senior |
$5.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.22
|
| Rate for Payer: Multiplan Commercial |
$6.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Senior |
$3.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.56
|
| Rate for Payer: Vantage Medical Group Senior |
$7.56
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 69238-1679-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Senior |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
IP
|
$1.28
|
|
|
Service Code
|
NDC 69238-1679-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| 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 |
$0.96
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 50268-367-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.25
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.69
|
| Rate for Payer: Dignity Health Senior |
$3.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.04
|
| Rate for Payer: Multiplan Commercial |
$3.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.74
|
| Rate for Payer: TriValley Medical Group Senior |
$1.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.69
|
| Rate for Payer: Vantage Medical Group Senior |
$3.69
|
|
