|
ALTEPLASE (CATHFLO) SYRINGE 2 MG/2 ML FOR NEBULIZATION [4081953]
|
Facility
|
OP
|
$201.54
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
ERX4081953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.85 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Cash Price |
$90.69
|
| Rate for Payer: Cash Price |
$82.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$110.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$120.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$120.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$110.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$120.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$110.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$110.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$120.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$151.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$137.75
|
|
|
ALTEPLASE (CATHFLO) SYRINGE 2 MG/2 ML FOR NEBULIZATION [4081953]
|
Facility
|
IP
|
$183.67
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
ERX4081953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.02 |
| Max. Negotiated Rate |
$146.94 |
| Rate for Payer: Cash Price |
$82.65
|
| Rate for Payer: Cash Price |
$90.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$146.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$161.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$120.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$110.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$151.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$137.75
|
|
|
ALTEPLASE INTRAVENTRICULAR 2 MG/2 ML SYRINGE [40820125]
|
Facility
|
IP
|
$201.54
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
ERX40820125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.85 |
| Max. Negotiated Rate |
$161.23 |
| Rate for Payer: Cash Price |
$90.69
|
| Rate for Payer: Cash Price |
$82.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$146.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$161.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$120.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$110.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$137.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$151.16
|
|
|
ALTEPLASE INTRAVENTRICULAR 2 MG/2 ML SYRINGE [40820125]
|
Facility
|
OP
|
$201.54
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
ERX40820125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.85 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$120.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$110.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$110.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$120.92
|
| Rate for Payer: Cash Price |
$90.69
|
| Rate for Payer: Cash Price |
$82.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$120.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$110.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$120.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$110.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$151.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$137.75
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-0091-85
|
| Hospital Charge Code |
NDG353B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-0091-85
|
| Hospital Charge Code |
NDG353B
|
|
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: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904-7727-14
|
| Hospital Charge Code |
1719042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904-7727-14
|
| Hospital Charge Code |
1719042
|
|
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: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
1716045
|
|
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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
1716045
|
|
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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9015]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1762-30
|
| Hospital Charge Code |
NDG9015
|
|
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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9015]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1762-30
|
| Hospital Charge Code |
NDG9015
|
|
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
|
|
|
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION [37605]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 0121-1760-30
|
| Hospital Charge Code |
1719150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION [37605]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 0121-1760-30
|
| Hospital Charge Code |
1719150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ALVIMOPAN 12 MG CAPSULE [91870]
|
Facility
|
IP
|
$218.21
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
ERX91870
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$120.02 |
| Max. Negotiated Rate |
$174.57 |
| Rate for Payer: Cash Price |
$98.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$130.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$163.66
|
|
|
ALVIMOPAN 12 MG CAPSULE [91870]
|
Facility
|
OP
|
$218.21
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
ERX91870
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$120.02 |
| Max. Negotiated Rate |
$163.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$130.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$130.93
|
| Rate for Payer: Cash Price |
$98.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$130.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$130.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$163.66
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0832-1015-00
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.73
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 68382-512-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.73
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 16571-834-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 16571-834-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 42543-493-01
|
| Hospital Charge Code |
1710713
|
|
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
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 42543-493-01
|
| Hospital Charge Code |
1710713
|
|
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
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 68382-512-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.73
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0832-1015-00
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.73
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
1715916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| 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: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
