|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 1672913501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 0378018101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 2930035001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0378018101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 5348915701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 2930035001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 6068768801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
ALLOPURINOL ORAL SUSPENSION COMPOUND 20MG/ML [4080236]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 9994080236
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.38
|
|
|
ALLOPURINOL ORAL SUSPENSION COMPOUND 20MG/ML [4080236]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 9994080236
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| 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 |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ALOE VERA TOPICAL GEL [111920]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 7166100136
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ALOE VERA TOPICAL GEL [111920]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 7166100136
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG (+/-)/20 ML IV SOLUTION [220820]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
HCPCS J0256
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG (+/-)/20 ML IV SOLUTION [220820]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
HCPCS J0256
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Intervalley Health Plan Commercial |
$5.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
ALPHA-LINOLENIC ACID OIL 7.7G/15 ML [4081057]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994081057
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| 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
|
|
|
ALPHA-LINOLENIC ACID OIL 7.7G/15 ML [4081057]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994081057
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| 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: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 6586267601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0228202710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 5976237191
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 6068737701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 6586267601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0228202710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 6068737701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 5976237191
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 6068737711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 6068737711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
