|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 6050508291
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.68
|
| 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 |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 6050508291
|
| 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: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
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: Aetna of CA Non-Gatekeeper |
$30.51
|
| Rate for Payer: Cash Price |
$21.32
|
| 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 Foundation Hospitals 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 |
$40.26 |
| Rate for Payer: Adventist Health Commercial |
$9.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.27
|
| 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 |
$35.11
|
| 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 |
$21.32
|
| Rate for Payer: Cash Price |
$21.32
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$22.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$205.15
|
|
|
Service Code
|
HCPCS 90673
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.13 |
| Max. Negotiated Rate |
$153.86 |
| Rate for Payer: Adventist Health Commercial |
$41.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$132.12
|
| Rate for Payer: Cash Price |
$92.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.98
|
| Rate for Payer: Heritage Provider Network Senior |
$94.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.29
|
| Rate for Payer: Multiplan Commercial |
$153.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$74.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.93
|
|
|
FLU VACCINE TV2025(9 YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE [246640]
|
Facility
|
OP
|
$205.15
|
|
|
Service Code
|
HCPCS 90673
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.13 |
| Max. Negotiated Rate |
$174.38 |
| Rate for Payer: Adventist Health Commercial |
$41.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$174.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$112.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$153.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$80.60
|
| 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 |
$92.32
|
| Rate for Payer: Cash Price |
$92.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$174.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$174.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$174.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.98
|
| Rate for Payer: Heritage Provider Network Senior |
$94.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$97.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$143.60
|
| Rate for Payer: Multiplan Commercial |
$153.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$82.06
|
| Rate for Payer: TriValley Medical Group Senior |
$82.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$74.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$174.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$174.38
|
| Rate for Payer: Vantage Medical Group Senior |
$174.38
|
|
|
FLUVOXAMINE 100 MG TABLET [10084]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 5107999301
|
| 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: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 Foundation Hospitals 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 5107999301
|
| 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 Non-Gatekeeper |
$0.43
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| 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 |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 6255915901
|
| 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: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Foundation Hospitals 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 5107999220
|
| 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 Non-Gatekeeper |
$0.37
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| 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 |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5107999201
|
| 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: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 6255915901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 5107999201
|
| 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 Non-Gatekeeper |
$0.37
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| 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 |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5107999220
|
| 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: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
IP
|
$9.72
|
|
|
Service Code
|
NDC 1037017611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.26
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.58
|
| Rate for Payer: Heritage Provider Network Senior |
$6.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.29
|
|
|
FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [91129]
|
Facility
|
OP
|
$9.72
|
|
|
Service Code
|
NDC 1037017611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.86
|
| Rate for Payer: Blue Shield of California Commercial |
$5.93
|
| Rate for Payer: Blue Shield of California EPN |
$4.74
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Senior |
$6.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.80
|
| Rate for Payer: Multiplan Commercial |
$7.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.89
|
| Rate for Payer: TriValley Medical Group Senior |
$3.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.26
|
| Rate for Payer: Vantage Medical Group Senior |
$8.26
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 6068768111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6068768111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 5374636101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 1153416501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 6068768101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6068768101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 5374636101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 1153416501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
