|
GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR [99835]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX99835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR [99835]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX99835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
GUAR GUM ORAL PACKET [30538]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 4390097647
|
| Hospital Charge Code |
ERX30538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| 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 |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
GUAR GUM ORAL PACKET [30538]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 4390097647
|
| Hospital Charge Code |
ERX30538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.43 |
| 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 |
$0.26
|
| 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 |
$0.43
|
|
|
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]
|
Facility
|
IP
|
$21.83
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
1720966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.37
|
|
|
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]
|
Facility
|
OP
|
$21.83
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
1720966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$176.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$176.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$176.80
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.37
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 51079-733-01
|
| Hospital Charge Code |
1710008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 51079-733-01
|
| Hospital Charge Code |
1710008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 51079-733-20
|
| Hospital Charge Code |
1710008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 51079-733-20
|
| Hospital Charge Code |
1710008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
HALOPERIDOL 10 MG TABLET [3580]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 0832-1550-11
|
| Hospital Charge Code |
1710056
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
HALOPERIDOL 10 MG TABLET [3580]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 68084-249-01
|
| Hospital Charge Code |
1710056
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.17
|
|
|
HALOPERIDOL 10 MG TABLET [3580]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 68084-249-11
|
| Hospital Charge Code |
1710056
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.17
|
|
|
HALOPERIDOL 10 MG TABLET [3580]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 0832-1550-11
|
| Hospital Charge Code |
1710056
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
HALOPERIDOL 10 MG TABLET [3580]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 68084-249-11
|
| Hospital Charge Code |
1710056
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.17
|
|
|
HALOPERIDOL 10 MG TABLET [3580]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 68084-249-01
|
| Hospital Charge Code |
1710056
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.17
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0378-0257-01
|
| Hospital Charge Code |
1710021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0781-1392-01
|
| Hospital Charge Code |
1710021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 51079-734-01
|
| Hospital Charge Code |
1710021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.37
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0378-0257-01
|
| Hospital Charge Code |
1710021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 51079-734-01
|
| Hospital Charge Code |
1710021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.37
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0781-1392-01
|
| Hospital Charge Code |
1710021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
HALOPERIDOL 2.5 MG 1/2 TABLET [4081945]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 60687-161-01
|
| Hospital Charge Code |
ERX4081945
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
HALOPERIDOL 2.5 MG 1/2 TABLET [4081945]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 60687-161-11
|
| Hospital Charge Code |
ERX4081945
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
HALOPERIDOL 2.5 MG 1/2 TABLET [4081945]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 51079-736-20
|
| Hospital Charge Code |
ERX4081945
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
