|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 50268-367-15
|
| 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
|
IP
|
$8.89
|
|
|
Service Code
|
NDC 0904-7158-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$6.67 |
| Rate for Payer: Adventist Health Commercial |
$1.78
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| 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 Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$6.67
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 51672-4234-1
|
| 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
|
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
|
$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
|
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
|
|
|
FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]
|
Facility
|
IP
|
$29.04
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
901700025
|
|
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: Cash Price |
$15.97
|
| 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 |
$13.45
|
| Rate for Payer: Heritage Provider Network Senior |
$13.45
|
| 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 |
$10.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.62
|
|
|
FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]
|
Facility
|
OP
|
$29.04
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$57.82 |
| Rate for Payer: Adventist Health Commercial |
$5.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.52
|
| 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 |
$57.82
|
| Rate for Payer: Blue Shield of California Commercial |
$23.32
|
| Rate for Payer: Blue Shield of California EPN |
$23.32
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cash Price |
$15.97
|
| 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 |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.85
|
| 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: Molina Healthcare of CA Medi-Cal |
$20.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.33
|
| 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 |
$10.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.68
|
| Rate for Payer: Vantage Medical Group Senior |
$24.68
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 0173-0696-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 0173-0696-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.94
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.91
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.33
|
| Rate for Payer: Dignity Health Senior |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Senior |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.57
|
| Rate for Payer: TriValley Medical Group Senior |
$1.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.33
|
| Rate for Payer: Vantage Medical Group Senior |
$3.33
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 0173-0697-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.50
|
| Rate for Payer: Dignity Health Senior |
$4.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Senior |
$3.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.71
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Senior |
$2.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.50
|
| Rate for Payer: Vantage Medical Group Senior |
$4.50
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 0173-0697-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.98 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.74
|
| 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
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.74
|
| 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 |
$0.64
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| 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: United Healthcare All Other HMO/non HMO |
$0.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
|
|
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [246638]
|
Facility
|
IP
|
$47.37
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$35.53 |
| Rate for Payer: Adventist Health Commercial |
$9.47
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.93
|
| Rate for Payer: Heritage Provider Network Senior |
$21.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.84
|
| Rate for Payer: Multiplan Commercial |
$35.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.68
|
|
|
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [246638]
|
Facility
|
OP
|
$47.37
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$50.78 |
| Rate for Payer: Adventist Health Commercial |
$9.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.78
|
| Rate for Payer: Blue Shield of California Commercial |
$20.00
|
| Rate for Payer: Blue Shield of California EPN |
$20.00
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.26
|
| Rate for Payer: Dignity Health Senior |
$40.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.93
|
| Rate for Payer: Heritage Provider Network Senior |
$21.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.16
|
| Rate for Payer: Multiplan Commercial |
$35.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.95
|
| Rate for Payer: TriValley Medical Group Senior |
$18.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.26
|
| Rate for Payer: Vantage Medical Group Senior |
$40.26
|
|
|
FLU VACCINE TV2025(9 YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE [246640]
|
Facility
|
OP
|
$188.21
|
|
|
Service Code
|
HCPCS 90673
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.07 |
| Max. Negotiated Rate |
$189.69 |
| Rate for Payer: Adventist Health Commercial |
$37.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$100.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$129.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$159.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$141.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$189.69
|
| Rate for Payer: Blue Shield of California Commercial |
$74.71
|
| Rate for Payer: Blue Shield of California EPN |
$74.71
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: Cash Price |
$103.52
|
| Rate for Payer: Cash Price |
$103.52
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$86.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$159.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$159.98
|
| Rate for Payer: Dignity Health Senior |
$159.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.14
|
| Rate for Payer: Heritage Provider Network Senior |
$87.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$89.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$131.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$131.75
|
| Rate for Payer: Multiplan Commercial |
$141.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$75.28
|
| Rate for Payer: TriValley Medical Group Senior |
$75.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$68.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$62.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$159.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$159.98
|
| Rate for Payer: Vantage Medical Group Senior |
$159.98
|
|
|
FLU VACCINE TV2025(9 YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE [246640]
|
Facility
|
IP
|
$188.21
|
|
|
Service Code
|
HCPCS 90673
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.07 |
| Max. Negotiated Rate |
$141.16 |
| Rate for Payer: Adventist Health Commercial |
$37.64
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: Cash Price |
$103.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$86.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.14
|
| Rate for Payer: Heritage Provider Network Senior |
$87.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.05
|
| Rate for Payer: Multiplan Commercial |
$141.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$68.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$62.32
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| 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
|
$0.70
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| 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 |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.39
|
| 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 |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.49
|
| 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: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| 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
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51079-992-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| 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: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| 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
|
$0.72
|
|
|
Service Code
|
NDC 62559-159-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.40
|
| 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 51079-992-20
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| 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: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| 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 |
901700029
|
|
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: Cash Price |
$0.33
|
| 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
|
|
