|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$1.12
|
|
|
Service Code
|
NDC 70710-1140-3
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
NDC 68462-104-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Senior |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
NDC 68462-104-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$3.46
|
|
|
Service Code
|
NDC 55111-146-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.94
|
| Rate for Payer: Dignity Health Senior |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.94
|
| Rate for Payer: Vantage Medical Group Senior |
$2.94
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$2.59
|
|
|
Service Code
|
NDC 59762-5018-1
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.20
|
| Rate for Payer: Dignity Health Senior |
$2.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
NDC 62559-993-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$0.79
|
|
|
Service Code
|
NDC 62559-993-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$3.46
|
|
|
Service Code
|
NDC 55111-146-30
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.38
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
NDC 67405-604-03
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-01
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.90
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.75
|
| Rate for Payer: Dignity Health Senior |
$2.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Vantage Medical Group Senior |
$2.75
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$2.45
|
|
|
Service Code
|
NDC 0904-6501-61
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Senior |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268-339-11
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268-339-11
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$2.45
|
|
|
Service Code
|
NDC 0904-6501-61
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.08
|
| Rate for Payer: Dignity Health Senior |
$2.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Vantage Medical Group Senior |
$2.08
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-11
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Senior |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-11
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.90
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.75
|
| Rate for Payer: Dignity Health Senior |
$2.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Vantage Medical Group Senior |
$2.75
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$75.11
|
|
|
Service Code
|
NDC 0049-3430-41
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.59 |
| Max. Negotiated Rate |
$56.33 |
| Rate for Payer: Adventist Health Commercial |
$15.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.60
|
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.85
|
| Rate for Payer: Heritage Provider Network Senior |
$50.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$56.33
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
NDC 0172-5413-46
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Senior |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$2.30
|
|
|
Service Code
|
NDC 68001-254-04
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
NDC 0172-5413-46
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$75.11
|
|
|
Service Code
|
NDC 0049-3430-41
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.59 |
| Max. Negotiated Rate |
$63.84 |
| Rate for Payer: Adventist Health Commercial |
$15.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$63.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$41.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$56.33
|
| Rate for Payer: Blue Shield of California Commercial |
$46.64
|
| Rate for Payer: Blue Shield of California EPN |
$44.09
|
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.84
|
| Rate for Payer: Dignity Health Senior |
$63.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.49
|
| Rate for Payer: Heritage Provider Network Senior |
$46.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$36.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$56.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.84
|
| Rate for Payer: Vantage Medical Group Senior |
$63.84
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
NDC 67405-604-03
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Senior |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
OP
|
$2.30
|
|
|
Service Code
|
NDC 68001-254-04
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.96
|
| Rate for Payer: Dignity Health Senior |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$3.23
|
|
|
Service Code
|
NDC 68084-735-01
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Senior |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
FLUCONAZOLE 200 MG TABLET [10045]
|
Facility
IP
|
$2.59
|
|
|
Service Code
|
NDC 59762-5018-1
|
| Hospital Charge Code |
1711489
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.78
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
|
