|
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION [226725]
|
Facility
|
IP
|
$4,771.80
|
|
|
Service Code
|
NDC 51144-030-01
|
| Hospital Charge Code |
ERX226725
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,624.49 |
| Max. Negotiated Rate |
$3,817.44 |
| Rate for Payer: Cash Price |
$2,147.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,817.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,863.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,624.49
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,578.85
|
|
|
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION [226725]
|
Facility
|
OP
|
$4,771.80
|
|
|
Service Code
|
NDC 51144-030-01
|
| Hospital Charge Code |
ERX226725
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,624.49 |
| Max. Negotiated Rate |
$3,578.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,863.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,863.08
|
| Rate for Payer: Cash Price |
$2,147.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,863.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2,863.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,624.49
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,578.85
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.20
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cash Price |
$5.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.46
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]
|
Facility
|
IP
|
$12.62
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Cash Price |
$5.68
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.46
|
|
|
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cash Price |
$20.12
|
| Rate for Payer: Cash Price |
$17.31
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$26.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$28.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$33.54
|
|
|
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]
|
Facility
|
OP
|
$44.72
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.60 |
| Max. Negotiated Rate |
$33.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$26.83
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.46
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$23.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$26.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$23.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.20
|
| Rate for Payer: Cash Price |
$17.31
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$20.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$26.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$26.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$23.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$33.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$28.84
|
|
|
ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION [105940]
|
Facility
|
IP
|
$12.80
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1753497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cash Price |
$13.40
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.33
|
|
|
ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION [105940]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1753497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.68
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.86
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.68
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$13.40
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]
|
Facility
|
OP
|
$26.79
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.07
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.33
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.86
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.40
|
| Rate for Payer: Cash Price |
$13.40
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$17.91
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]
|
Facility
|
IP
|
$26.79
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$21.43 |
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cash Price |
$13.40
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$17.91
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.36
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.36
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.09
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]
|
Facility
|
IP
|
$12.27
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$9.82 |
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]
|
Facility
|
IP
|
$29.80
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$23.84 |
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.35
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]
|
Facility
|
OP
|
$29.80
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$22.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.00
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]
|
Facility
|
OP
|
$26.82
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721093
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.75 |
| Max. Negotiated Rate |
$20.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.09
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.09
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]
|
Facility
|
IP
|
$26.82
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721093
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.75 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.12
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-21
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.96
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.70
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-11
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.70
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-11
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.96
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.70
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-21
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.70
|
|
|
ENTECAVIR 0.05 MG/ML ORAL SOLUTION [41149]
|
Facility
|
OP
|
$5.49
|
|
|
Service Code
|
NDC 0003-1614-12
|
| Hospital Charge Code |
1715226
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.29
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.12
|
|
|
ENTECAVIR 0.05 MG/ML ORAL SOLUTION [41149]
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 0003-1614-12
|
| Hospital Charge Code |
1715226
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.12
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 31722-833-30
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.20
|
|
