|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.73
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.42
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.73
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.42
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.42
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$11.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.25
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.56
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$12.34 |
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.56
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.00
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.00
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-02
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.88
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.76
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-02
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.88
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.31
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.76
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.76
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.31
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.88
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.88
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.31
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.89
|
|
|
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]
|
Facility
|
OP
|
$244.80
|
|
|
Service Code
|
CPT J0883
|
| Hospital Charge Code |
1759990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.64 |
| Max. Negotiated Rate |
$183.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$146.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$78.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$78.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$146.88
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$146.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$78.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$78.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$146.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$183.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$97.81
|
|
|
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]
|
Facility
|
IP
|
$244.80
|
|
|
Service Code
|
CPT J0883
|
| Hospital Charge Code |
1759990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.64 |
| Max. Negotiated Rate |
$195.84 |
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$104.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$195.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$78.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$146.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$97.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$183.60
|
|
