|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0832-1015-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.73
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 42543-493-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| 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 |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| 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 Commercial |
$0.36
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 16571-834-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| 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 Commercial |
$0.09
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 60687-422-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.31
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-56
|
| 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 |
$0.27
|
| 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 Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| 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
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-42
|
| 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 |
$0.27
|
| 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 Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.27
|
| 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
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| 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 |
$0.04
|
| 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: 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 Commercial |
$0.05
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.27
|
| 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
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.34 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.65
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$36.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.34
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.89 |
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$329.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$329.91
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$329.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.34 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$36.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.34
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.88 |
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$329.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$329.92
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$329.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.88 |
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.34 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.65
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$36.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.34
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.89 |
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.34 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$36.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.34
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$329.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$329.91
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$329.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$302.42 |
| Max. Negotiated Rate |
$439.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$329.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$329.92
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$439.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$329.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$329.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.57
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.88
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.43 |
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
