|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$582.30
|
|
|
Service Code
|
NDC 6195808015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$320.26 |
| Max. Negotiated Rate |
$465.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$349.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$349.38
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$465.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$349.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$349.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$320.26
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$2.57
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.19
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$2.16
|
| 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 |
$4.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$4.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.88
|
| 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 |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
IP
|
$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: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$1.93
|
| 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 |
$5.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| 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: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
IP
|
$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: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.72
|
| 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: 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: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.56
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| 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 |
$2.02
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.09
|
| 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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/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
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0574029201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| 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: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0574029201
|
| 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
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 3172203523
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
NDC 3172203523
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 7037710211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.30
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$4.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 6068773925
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.22
|
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$17.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 6068773995
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.22
|
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$17.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 6068773995
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 7037710211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 7220504930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Cash Price |
$5.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.15
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 6968011530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 6968011530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.30
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$4.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 6068773925
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 7220504930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.80
|
| Rate for Payer: Cash Price |
$5.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.15
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
AMINOLEVULINIC ACID HCL 30 MG/ML ORAL SOLUTION [222763]
|
Facility
|
IP
|
$3,835.20
|
|
|
Service Code
|
NDC 5913723101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,109.36 |
| Max. Negotiated Rate |
$3,068.16 |
| Rate for Payer: Cash Price |
$1,725.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3,068.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,301.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,109.36
|
| Rate for Payer: Multiplan Commercial |
$2,876.40
|
|
|
AMINOLEVULINIC ACID HCL 30 MG/ML ORAL SOLUTION [222763]
|
Facility
|
OP
|
$3,835.20
|
|
|
Service Code
|
NDC 5913723101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,109.36 |
| Max. Negotiated Rate |
$3,068.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,301.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,301.12
|
| Rate for Payer: Cash Price |
$1,725.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3,068.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,301.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2,301.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,109.36
|
| Rate for Payer: Multiplan Commercial |
$2,876.40
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.74
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
