|
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION [99465]
|
Facility
|
IP
|
$1,030.80
|
|
|
Service Code
|
CPT J0586
|
| Hospital Charge Code |
ERX99465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$566.94 |
| Max. Negotiated Rate |
$824.64 |
| Rate for Payer: Cash Price |
$463.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$824.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$618.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$566.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$773.10
|
|
|
ACARBOSE 50 MG TABLET [15895]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 0054-0141-25
|
| Hospital Charge Code |
1711694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.46
|
|
|
ACARBOSE 50 MG TABLET [15895]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 0054-0141-25
|
| Hospital Charge Code |
1711694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.46
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
NDG108021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.28
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
NDG108021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.28
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
1753544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.26
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
1753544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| 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 |
$0.15
|
| 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 Beech St/Commercial/PHCS |
$0.26
|
|
|
ACETAMINOPHEN 100 MG/10 ML (10 MG/ML) INTRAVENOUS SYRINGE [4080108021]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
NDG108021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.28
|
|
|
ACETAMINOPHEN 100 MG/10 ML (10 MG/ML) INTRAVENOUS SYRINGE [4080108021]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
NDG108021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.28
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION [199408]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0121-0504-00
|
| Hospital Charge Code |
1717108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION [199408]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0121-0504-00
|
| Hospital Charge Code |
1717108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION [199408]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0121-0504-05
|
| Hospital Charge Code |
1717108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION [199408]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0121-0504-05
|
| Hospital Charge Code |
1717108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION [110535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0121-0504-04
|
| Hospital Charge Code |
NDG110535B
|
|
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
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION [110535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 60432-245-16
|
| Hospital Charge Code |
NDG110535A
|
|
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
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION [110535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 60432-245-16
|
| Hospital Charge Code |
NDG110535A
|
|
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
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION [110535]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 50383-079-16
|
| Hospital Charge Code |
NDG110535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION [110535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0121-0504-04
|
| Hospital Charge Code |
NDG110535B
|
|
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
|
|
|
ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION [110535]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 50383-079-16
|
| Hospital Charge Code |
NDG110535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 0472-1201-01
|
| Hospital Charge Code |
1748002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.60
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 0472-1201-01
|
| Hospital Charge Code |
1748002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.60
|
|
|
ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID [100]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904-7014-16
|
| Hospital Charge Code |
NDG16962A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID [100]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904-7014-16
|
| Hospital Charge Code |
NDG16962A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID. [408100]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904-7014-16
|
| Hospital Charge Code |
NDG16962A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID. [408100]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 68094-330-62
|
| Hospital Charge Code |
1717202
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.05
|
| 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 Beech St/Commercial/PHCS |
$0.09
|
|
