|
ETRAVIRINE 100 MG TABLET [89432]
|
Facility
|
IP
|
$14.98
|
|
|
Service Code
|
NDC 59676-570-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$11.98 |
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.24
|
| Rate for Payer: Multiplan Commercial |
$11.23
|
|
|
ETRAVIRINE 100 MG TABLET [89432]
|
Facility
|
OP
|
$14.98
|
|
|
Service Code
|
NDC 59676-570-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$11.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.99
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.24
|
| Rate for Payer: Multiplan Commercial |
$11.23
|
|
|
ETRAVIRINE 200 MG TABLET [108431]
|
Facility
|
IP
|
$29.96
|
|
|
Service Code
|
NDC 59676-571-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$23.97 |
| Rate for Payer: Cash Price |
$16.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.48
|
| Rate for Payer: Multiplan Commercial |
$22.47
|
|
|
ETRAVIRINE 200 MG TABLET [108431]
|
Facility
|
OP
|
$29.96
|
|
|
Service Code
|
NDC 59676-571-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$23.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.98
|
| Rate for Payer: Cash Price |
$16.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.48
|
| Rate for Payer: Multiplan Commercial |
$22.47
|
|
|
EUCALYPTUS OIL-ALOE EXTR-LAVENDER,ROSEMARY OIL-PETROLATUM TOP OINTMENT [9125]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 2390000617
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
EUCALYPTUS OIL-ALOE EXTR-LAVENDER,ROSEMARY OIL-PETROLATUM TOP OINTMENT [9125]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 2390000617
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
EVEROLIMUS 0.3 MG/ML SPECIAL DILUTION (FROM 0.75 MG TAB) [4081261]
|
Facility
|
IP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$31.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
|
|
EVEROLIMUS 0.3 MG/ML SPECIAL DILUTION (FROM 0.75 MG TAB) [4081261]
|
Facility
|
OP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$23.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$23.71
|
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$31.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$23.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET [104555]
|
Facility
|
OP
|
$13.16
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.90
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET [104555]
|
Facility
|
IP
|
$13.16
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.24
|
| Rate for Payer: Multiplan Commercial |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG TABLET [104877]
|
Facility
|
IP
|
$26.36
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.50 |
| Max. Negotiated Rate |
$21.09 |
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.41
|
| Rate for Payer: Multiplan Commercial |
$19.74
|
| Rate for Payer: Multiplan Commercial |
$7.38
|
| Rate for Payer: Multiplan Commercial |
$19.77
|
| Rate for Payer: Multiplan Commercial |
$14.27
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG TABLET [104877]
|
Facility
|
OP
|
$19.03
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.42
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.82
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.82
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.48
|
| Rate for Payer: Multiplan Commercial |
$19.74
|
| Rate for Payer: Multiplan Commercial |
$19.77
|
| Rate for Payer: Multiplan Commercial |
$7.38
|
| Rate for Payer: Multiplan Commercial |
$14.27
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.75 MG TABLET [104556]
|
Facility
|
OP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$23.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$23.71
|
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$31.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$23.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.75 MG TABLET [104556]
|
Facility
|
IP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$31.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
IP
|
$13.03
|
|
|
Service Code
|
NDC 0054-0080-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$10.42 |
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.17
|
| Rate for Payer: Multiplan Commercial |
$9.77
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
OP
|
$13.03
|
|
|
Service Code
|
NDC 0054-0080-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$10.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.82
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.17
|
| Rate for Payer: Multiplan Commercial |
$9.77
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
OP
|
$46.05
|
|
|
Service Code
|
NDC 0009-7663-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$36.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.63
|
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$36.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.33
|
| Rate for Payer: Multiplan Commercial |
$34.54
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
IP
|
$46.05
|
|
|
Service Code
|
NDC 0009-7663-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$36.84 |
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$36.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.33
|
| Rate for Payer: Multiplan Commercial |
$34.54
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 59651-052-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 59651-052-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
FACTOR XIII 1,000 UNIT-1,600 UNIT INTRAVENOUS SOLUTION [108721]
|
Facility
|
OP
|
$15.34
|
|
|
Service Code
|
HCPCS J7180
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.20
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Multiplan Commercial |
$11.51
|
|
