|
CIPROFLOXACIN 750 MG TABLET [25120]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 55111-128-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 70069-161-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$2.79
|
|
|
Service Code
|
NDC 0409-1208-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.67
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 71288-712-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$2.79
|
|
|
Service Code
|
NDC 0409-1208-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.67
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 71288-712-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 63323-417-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 63323-417-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 70069-161-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 63323-417-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 70069-161-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 63323-417-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 70069-161-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$2.79
|
|
|
Service Code
|
NDC 0409-1208-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 71288-712-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$2.79
|
|
|
Service Code
|
NDC 0409-1208-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [16168]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 71288-712-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88377]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
HCPCS J9060
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88377]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
HCPCS J9060
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
CITALOPRAM 10 MG/5 ML ORAL SOLUTION [28228]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 31722-564-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
CITALOPRAM 10 MG/5 ML ORAL SOLUTION [28228]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 31722-564-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
CITALOPRAM 10 MG/5 ML ORAL SOLUTION [28228]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 0054-0062-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
CITALOPRAM 10 MG/5 ML ORAL SOLUTION [28228]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 0054-0062-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
CITALOPRAM 10 MG TABLET [30264]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0378-6231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
CITALOPRAM 10 MG TABLET [30264]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 13668-009-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
