|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]
|
Facility
|
IP
|
$8.53
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$6.82 |
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.40
|
|
|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]
|
Facility
|
OP
|
$8.53
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.65
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.06
|
|
|
AMPICILLIN 500 MG CAPSULE [466]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 0781-2145-01
|
| Hospital Charge Code |
1710493
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| 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 |
$0.28
|
| 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 |
$0.47
|
|
|
AMPICILLIN 500 MG CAPSULE [466]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0781-2145-01
|
| Hospital Charge Code |
1710493
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| 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 |
$0.47
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.13
|
|
|
AMPICILLIN-SULBACTAM 15 GRAM SOLUTION FOR INJECTION [32469]
|
Facility
|
IP
|
$66.60
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
ERX32469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.63 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Cash Price |
$29.97
|
| Rate for Payer: Cash Price |
$39.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$39.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$65.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$49.95
|
|
|
AMPICILLIN-SULBACTAM 15 GRAM SOLUTION FOR INJECTION [32469]
|
Facility
|
OP
|
$87.37
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
ERX32469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.05 |
| Max. Negotiated Rate |
$65.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$52.42
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$39.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$52.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$39.96
|
| Rate for Payer: Cash Price |
$39.32
|
| Rate for Payer: Cash Price |
$29.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$39.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$52.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$39.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$65.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$49.95
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [32470]
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
ERX32470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.45
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [32470]
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
ERX32470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.96
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.55
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.96
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.94
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [32471]
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
1752190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cash Price |
$7.86
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.77
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.10
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [32471]
|
Facility
|
OP
|
$6.43
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
1752190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.86
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.82
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.82
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cash Price |
$7.86
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.77
|
|
|
ANAGRELIDE 0.5 MG CAPSULE [20446]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 13668-453-01
|
| Hospital Charge Code |
1711743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.75
|
|
|
ANAGRELIDE 0.5 MG CAPSULE [20446]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0172-5241-60
|
| Hospital Charge Code |
1711743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.75
|
|
|
ANAGRELIDE 0.5 MG CAPSULE [20446]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0172-5241-60
|
| Hospital Charge Code |
1711743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.75
|
|
|
ANAGRELIDE 0.5 MG CAPSULE [20446]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 13668-453-01
|
| Hospital Charge Code |
1711743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.75
|
|
|
ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE [31784]
|
Facility
|
OP
|
$329.59
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
1712540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.27 |
| Max. Negotiated Rate |
$247.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$197.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$197.75
|
| Rate for Payer: Cash Price |
$148.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$197.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$197.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$247.19
|
|
|
ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE [31784]
|
Facility
|
IP
|
$329.59
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
1712540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.27 |
| Max. Negotiated Rate |
$263.67 |
| Rate for Payer: Cash Price |
$148.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$263.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$197.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$247.19
|
|
|
ANASTROZOLE 1 MG TABLET [16205]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
CPT S0170
|
| Hospital Charge Code |
1711729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
ANASTROZOLE 1 MG TABLET [16205]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
CPT S0170
|
| Hospital Charge Code |
1711729
|
|
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 EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
ANGIOTENSIN II 2.5 MG/ML INTRAVENOUS SOLUTION [220829]
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG220829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$990.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Cash Price |
$810.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,440.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,080.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$990.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,350.00
|
|
|
ANGIOTENSIN II 2.5 MG/ML INTRAVENOUS SOLUTION [220829]
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG220829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$990.00 |
| Max. Negotiated Rate |
$1,350.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,080.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,080.00
|
| Rate for Payer: Cash Price |
$810.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,080.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,080.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$990.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,350.00
|
|
|
ANIDULAFUNGIN 100 MG INTRAVENOUS SOLUTION [88093]
|
Facility
|
IP
|
$229.07
|
|
|
Service Code
|
CPT J0348
|
| Hospital Charge Code |
1753552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.99 |
| Max. Negotiated Rate |
$183.26 |
| Rate for Payer: Cash Price |
$103.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$183.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$137.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$171.80
|
|
|
ANIDULAFUNGIN 100 MG INTRAVENOUS SOLUTION [88093]
|
Facility
|
OP
|
$229.07
|
|
|
Service Code
|
CPT J0348
|
| Hospital Charge Code |
1753552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.99 |
| Max. Negotiated Rate |
$171.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$137.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$137.44
|
| Rate for Payer: Cash Price |
$103.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$137.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$137.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$171.80
|
|
|
ANTICOAG CITRATE/DEXTROSE CPD UNIT 450 ML [4081055]
|
Facility
|
IP
|
$55.87
|
|
|
Service Code
|
NDC 9994-0810-55
|
| Hospital Charge Code |
1771241
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.73 |
| Max. Negotiated Rate |
$44.70 |
| Rate for Payer: Cash Price |
$25.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$41.90
|
|
