|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
IP
|
$3.35
|
|
|
Service Code
|
NDC 69543-131-20
|
| Hospital Charge Code |
1710931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.51
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 64980-342-14
|
| Hospital Charge Code |
1710931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
OP
|
$1.65
|
|
|
Service Code
|
NDC 65862-329-04
|
| Hospital Charge Code |
1710931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.99
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.24
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 64980-342-14
|
| Hospital Charge Code |
1710931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
IP
|
$1.65
|
|
|
Service Code
|
NDC 65862-329-04
|
| Hospital Charge Code |
1710931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.24
|
|
|
ALFENTANIL 500 MCG/ML INJECTION SOLUTION [25268]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
CPT J0216
|
| Hospital Charge Code |
1737010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
ALFENTANIL 500 MCG/ML INJECTION SOLUTION [25268]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
CPT J0216
|
| Hospital Charge Code |
1737010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR [36982]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 47335-956-88
|
| Hospital Charge Code |
1710956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR [36982]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 13668-021-01
|
| Hospital Charge Code |
1710956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR [36982]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 47335-956-88
|
| Hospital Charge Code |
1710956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR [36982]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 13668-021-01
|
| Hospital Charge Code |
1710956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
ALGLUCOSIDASE ALFA 50 MG INTRAVENOUS SOLUTION [76353]
|
Facility
|
OP
|
$1,123.61
|
|
|
Service Code
|
CPT J0221
|
| Hospital Charge Code |
1755758
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$617.99 |
| Max. Negotiated Rate |
$842.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$674.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$674.17
|
| Rate for Payer: Cash Price |
$505.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$674.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$674.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$617.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$842.71
|
|
|
ALGLUCOSIDASE ALFA 50 MG INTRAVENOUS SOLUTION [76353]
|
Facility
|
IP
|
$1,123.61
|
|
|
Service Code
|
CPT J0221
|
| Hospital Charge Code |
1755758
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$617.99 |
| Max. Negotiated Rate |
$898.89 |
| Rate for Payer: Cash Price |
$505.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$898.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$674.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$617.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$842.71
|
|
|
AL HYD-MG TR-ALG AC-SOD BICARB 80 MG-14.2 MG CHEWABLE TABLET [88365]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0088-1175-47
|
| Hospital Charge Code |
1710445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
AL HYD-MG TR-ALG AC-SOD BICARB 80 MG-14.2 MG CHEWABLE TABLET [88365]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0088-1175-47
|
| Hospital Charge Code |
1710445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| 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 |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
ALISKIREN 150 MG TABLET [78653]
|
Facility
|
IP
|
$11.63
|
|
|
Service Code
|
NDC 70839-150-30
|
| Hospital Charge Code |
1711903
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$9.30 |
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.72
|
|
|
ALISKIREN 150 MG TABLET [78653]
|
Facility
|
OP
|
$11.63
|
|
|
Service Code
|
NDC 70839-150-30
|
| Hospital Charge Code |
1711903
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$8.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.98
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.72
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 29300-349-01
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 53489-156-01
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 62584-988-01
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 62584-988-11
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 53489-156-01
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 29300-349-01
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 62584-988-01
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 0904-7041-61
|
| Hospital Charge Code |
1711276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.30 |
| 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 |
$0.18
|
| 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 Beech St/Commercial/PHCS |
$0.30
|
|
