|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.01 |
| Max. Negotiated Rate |
$77.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.83
|
| Rate for Payer: Cash Price |
$53.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$77.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.01
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$83.76
|
|
|
Service Code
|
NDC 67877-749-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.07 |
| Max. Negotiated Rate |
$67.01 |
| Rate for Payer: Cash Price |
$46.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$67.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$50.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.07
|
| Rate for Payer: Multiplan Commercial |
$62.82
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.01 |
| Max. Negotiated Rate |
$77.10 |
| Rate for Payer: Cash Price |
$53.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$77.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.01
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.01 |
| Max. Negotiated Rate |
$77.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.83
|
| Rate for Payer: Cash Price |
$53.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$77.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.01
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.01 |
| Max. Negotiated Rate |
$77.10 |
| Rate for Payer: Cash Price |
$53.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$77.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.01
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
IP
|
$24.26
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$19.41 |
| Rate for Payer: Cash Price |
$13.34
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.97
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$13.34
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
OP
|
$14.55
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.73
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.73
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Multiplan Commercial |
$10.91
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$10.91
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
IP
|
$14.55
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cash Price |
$13.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: Multiplan Commercial |
$10.91
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
OP
|
$24.26
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$19.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.56
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.73
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cash Price |
$13.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$10.91
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [32767]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J9394
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [32767]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J9394
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$72.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$72.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [32767]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.40
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [32767]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
FUROSEMIDE 10 MG/ML CONTINUOUS INFUSION (UNDILUTED) [4083291]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 |
$0.15
|
| 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 Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
FUROSEMIDE 10 MG/ML CONTINUOUS INFUSION (UNDILUTED) [4083291]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.15
|
| 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
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.54
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0054-3294-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0054-3294-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0054-3294-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0054-3294-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
FUROSEMIDE 20 MG TABLET [3294]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 51079-072-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
FUROSEMIDE 20 MG TABLET [3294]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 51079-072-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| 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 |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
