|
ELETRIPTAN 40 MG TABLET [34684]
|
Facility
|
OP
|
$92.31
|
|
|
Service Code
|
NDC 0049-2340-45
|
| Hospital Charge Code |
1711914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.77 |
| Max. Negotiated Rate |
$69.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$55.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$55.39
|
| Rate for Payer: Cash Price |
$41.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$55.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$55.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.77
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$69.23
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
IP
|
$2,573.28
|
|
|
Service Code
|
NDC 0003-2291-11
|
| Hospital Charge Code |
ERX212322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,415.30 |
| Max. Negotiated Rate |
$2,058.62 |
| Rate for Payer: Cash Price |
$1,157.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,058.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,543.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,415.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,929.96
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
OP
|
$2,573.28
|
|
|
Service Code
|
NDC 0003-2291-11
|
| Hospital Charge Code |
ERX212322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,415.30 |
| Max. Negotiated Rate |
$1,929.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,543.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,543.97
|
| Rate for Payer: Cash Price |
$1,157.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,543.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,543.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,415.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,929.96
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
OP
|
$3,431.02
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
ERX212323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,887.06 |
| Max. Negotiated Rate |
$2,573.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,058.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,058.61
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,058.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2,058.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,887.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,573.26
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
IP
|
$3,431.02
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
ERX212323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,887.06 |
| Max. Negotiated Rate |
$2,744.82 |
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,744.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,058.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,887.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,573.26
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$268.39
|
|
|
Service Code
|
NDC 0078-0685-15
|
| Hospital Charge Code |
ERX94579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$147.61 |
| Max. Negotiated Rate |
$214.71 |
| Rate for Payer: Cash Price |
$120.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$214.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$161.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$201.29
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$268.39
|
|
|
Service Code
|
NDC 0078-0685-15
|
| Hospital Charge Code |
ERX94579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$147.61 |
| Max. Negotiated Rate |
$201.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$161.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$161.03
|
| Rate for Payer: Cash Price |
$120.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$161.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$161.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$201.29
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
IP
|
$485.71
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
ERX94580
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$267.14 |
| Max. Negotiated Rate |
$388.57 |
| Rate for Payer: Cash Price |
$218.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$388.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$291.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$267.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$364.28
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
OP
|
$485.71
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
ERX94580
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$267.14 |
| Max. Negotiated Rate |
$364.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$291.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$291.43
|
| Rate for Payer: Cash Price |
$218.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$291.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$291.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$267.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$364.28
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
IP
|
$2,026.21
|
|
|
Service Code
|
CPT J9210
|
| Hospital Charge Code |
NDG223872A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,114.42 |
| Max. Negotiated Rate |
$1,620.97 |
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,620.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,215.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,114.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,519.66
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
OP
|
$2,026.21
|
|
|
Service Code
|
CPT J9210
|
| Hospital Charge Code |
NDG223872A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,114.42 |
| Max. Negotiated Rate |
$1,519.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,215.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,215.73
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,215.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,114.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,519.66
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
NDG196535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| 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 |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
NDG196535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 9994-0807-70
|
| Hospital Charge Code |
1743584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$35.74
|
|
|
Service Code
|
NDC 98193-000-17
|
| Hospital Charge Code |
NDG4080770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$26.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.44
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.80
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 98193-00005
|
| Hospital Charge Code |
NDG4080770B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.84
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.55
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 98193-00005
|
| Hospital Charge Code |
NDG4080770B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.55
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$35.74
|
|
|
Service Code
|
NDC 98193-000-17
|
| Hospital Charge Code |
NDG4080770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$28.59 |
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.80
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 99408-770-02
|
| Hospital Charge Code |
1743780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.07
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.83
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 99408-770-02
|
| Hospital Charge Code |
1743780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.83
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 9994-0807-70
|
| Hospital Charge Code |
1743584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
