|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0904734661
|
| 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 Non-Gatekeeper |
$0.07
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| 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 |
$0.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 TABLET [17463]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 5965130930
|
| 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 Non-Gatekeeper |
$0.23
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| 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 |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5965130930
|
| 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: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0121065402
|
| 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 Non-Gatekeeper |
$0.40
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| 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 |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0121065402
|
| 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: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 5167242341
|
| 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 Non-Gatekeeper |
$0.79
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| 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 |
$0.58
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 6923816791
|
| 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: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.58
|
| 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 Foundation Hospitals 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
|
IP
|
$2.78
|
|
|
Service Code
|
NDC 0527178901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$2.78
|
|
|
Service Code
|
NDC 0527178901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2.36
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 5026836711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.69
|
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.68
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.17
|
| 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 |
$1.95
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$3.69
|
|
|
FLUPHENAZINE 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 6923816791
|
| 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 Non-Gatekeeper |
$0.79
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| 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 |
$0.58
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$4.34
|
|
|
Service Code
|
NDC 5026836715
|
| 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 Non-Gatekeeper |
$2.68
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.17
|
| 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 |
$1.95
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 2.5 MG TABLET [3220]
|
Facility
|
OP
|
$8.89
|
|
|
Service Code
|
NDC 0904715861
|
| 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 Non-Gatekeeper |
$5.49
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$4.45
|
| 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 |
$4.00
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$4.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 5026836711
|
| 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: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: Cash Price |
$1.95
|
| 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 Foundation Hospitals 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
|
$4.34
|
|
|
Service Code
|
NDC 5026836715
|
| 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: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: Cash Price |
$1.95
|
| 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 Foundation Hospitals 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 0904715861
|
| 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: Aetna of CA Non-Gatekeeper |
$5.73
|
| Rate for Payer: Cash Price |
$4.00
|
| 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 Foundation Hospitals 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
|
IP
|
$1.28
|
|
|
Service Code
|
NDC 5167242341
|
| 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: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.58
|
| 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 Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
|
|
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 |
$121.14 |
| Rate for Payer: Adventist Health Commercial |
$5.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.95
|
| 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 |
$121.14
|
| 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 |
$13.07
|
| Rate for Payer: Cash Price |
$13.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$13.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
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: Aetna of CA Non-Gatekeeper |
$18.70
|
| Rate for Payer: Cash Price |
$13.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.45
|
| Rate for Payer: Heritage Provider Network Senior |
$13.45
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 0173069600
|
| 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: Aetna of CA Non-Gatekeeper |
$2.52
|
| Rate for Payer: Cash Price |
$1.76
|
| 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 Foundation Hospitals 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 0173069600
|
| 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 Non-Gatekeeper |
$2.42
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.96
|
| 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 |
$1.76
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 0173069700
|
| 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: Aetna of CA Non-Gatekeeper |
$3.41
|
| Rate for Payer: Cash Price |
$2.38
|
| 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 Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 0173069700
|
| 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 Non-Gatekeeper |
$3.28
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.65
|
| 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 |
$2.38
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]
|
Facility
|
IP
|
$17.80
|
|
|
Service Code
|
NDC 6699307996
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$13.35 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.46
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.05
|
| Rate for Payer: Heritage Provider Network Senior |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Commercial |
$13.35
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]
|
Facility
|
OP
|
$17.80
|
|
|
Service Code
|
NDC 6699307996
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$15.13 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.90
|
| Rate for Payer: Blue Shield of California Commercial |
$10.86
|
| Rate for Payer: Blue Shield of California EPN |
$8.69
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.02
|
| Rate for Payer: Heritage Provider Network Senior |
$11.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$13.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.12
|
| Rate for Payer: TriValley Medical Group Senior |
$7.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.13
|
| Rate for Payer: Vantage Medical Group Senior |
$15.13
|
|
