ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
|
OP
|
$0.86
|
|
Service Code
|
NDC 0065-8064-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.47 |
Max. Negotiated Rate |
$0.69 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
Rate for Payer: Cash Price |
$0.47
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
Rate for Payer: Multiplan Commercial |
$0.65
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
|
IP
|
$0.86
|
|
Service Code
|
NDC 0065-8064-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.47 |
Max. Negotiated Rate |
$0.69 |
Rate for Payer: Cash Price |
$0.47
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
Rate for Payer: Multiplan Commercial |
$0.65
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
|
OP
|
$447.30
|
|
Service Code
|
NDC 0078-1091-20
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$246.01 |
Max. Negotiated Rate |
$357.84 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$268.38
|
Rate for Payer: Aetna of CA Government/Medicare |
$268.38
|
Rate for Payer: Cash Price |
$246.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$357.84
|
Rate for Payer: Health Smart Auto/Commercial |
$268.38
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$268.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$246.01
|
Rate for Payer: Multiplan Commercial |
$335.48
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
|
IP
|
$447.30
|
|
Service Code
|
NDC 0078-1091-20
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$246.01 |
Max. Negotiated Rate |
$357.84 |
Rate for Payer: Cash Price |
$246.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$357.84
|
Rate for Payer: Health Smart Auto/Commercial |
$268.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$246.01
|
Rate for Payer: Multiplan Commercial |
$335.48
|
|
ASCIMINIB 40 MG TABLET [233025]
|
Facility
|
OP
|
$447.30
|
|
Service Code
|
NDC 0078-1098-20
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$246.01 |
Max. Negotiated Rate |
$357.84 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$268.38
|
Rate for Payer: Aetna of CA Government/Medicare |
$268.38
|
Rate for Payer: Cash Price |
$246.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$357.84
|
Rate for Payer: Health Smart Auto/Commercial |
$268.38
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$268.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$246.01
|
Rate for Payer: Multiplan Commercial |
$335.48
|
|
ASCIMINIB 40 MG TABLET [233025]
|
Facility
|
IP
|
$447.30
|
|
Service Code
|
NDC 0078-1098-20
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$246.01 |
Max. Negotiated Rate |
$357.84 |
Rate for Payer: Cash Price |
$246.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$357.84
|
Rate for Payer: Health Smart Auto/Commercial |
$268.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$246.01
|
Rate for Payer: Multiplan Commercial |
$335.48
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL LIQUID [227420]
|
Facility
|
IP
|
$0.06
|
|
Service Code
|
NDC 6961801854
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.05
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL LIQUID [227420]
|
Facility
|
OP
|
$0.06
|
|
Service Code
|
NDC 6961801854
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.05
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL SYRUP [115152]
|
Facility
|
IP
|
$0.03
|
|
Service Code
|
NDC 5789684216
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL SYRUP [115152]
|
Facility
|
OP
|
$0.03
|
|
Service Code
|
NDC 5789684216
|
Hospital Charge Code |
901700029
|
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 |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]
|
Facility
|
IP
|
$2.17
|
|
Service Code
|
NDC 67457-118-50
|
Hospital Charge Code |
901700004
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.19 |
Max. Negotiated Rate |
$1.74 |
Rate for Payer: Cash Price |
$1.19
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
Rate for Payer: Multiplan Commercial |
$1.63
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]
|
Facility
|
OP
|
$2.17
|
|
Service Code
|
NDC 67457-118-50
|
Hospital Charge Code |
901700004
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.19 |
Max. Negotiated Rate |
$1.74 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
Rate for Payer: Cash Price |
$1.19
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
Rate for Payer: Multiplan Commercial |
$1.63
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
|
IP
|
$6.42
|
|
Service Code
|
NDC 67157-101-51
|
Hospital Charge Code |
901700004
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$3.53 |
Max. Negotiated Rate |
$5.14 |
Rate for Payer: Cash Price |
$3.53
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.14
|
Rate for Payer: Health Smart Auto/Commercial |
$3.85
|
Rate for Payer: LLUH Dept of Risk Management WC |
$3.53
|
Rate for Payer: Multiplan Commercial |
$4.82
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
|
OP
|
$6.49
|
|
Service Code
|
NDC 67157-101-50
|
Hospital Charge Code |
901700004
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$3.57 |
Max. Negotiated Rate |
$5.19 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.89
|
Rate for Payer: Aetna of CA Government/Medicare |
$3.89
|
Rate for Payer: Cash Price |
$3.57
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.19
|
Rate for Payer: Health Smart Auto/Commercial |
$3.89
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.89
|
Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
Rate for Payer: Multiplan Commercial |
$4.87
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
|
IP
|
$6.49
|
|
Service Code
|
NDC 67157-101-50
|
Hospital Charge Code |
901700004
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$3.57 |
Max. Negotiated Rate |
$5.19 |
Rate for Payer: Cash Price |
$3.57
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.19
|
Rate for Payer: Health Smart Auto/Commercial |
$3.89
|
Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
Rate for Payer: Multiplan Commercial |
$4.87
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
|
OP
|
$6.42
|
|
Service Code
|
NDC 67157-101-51
|
Hospital Charge Code |
901700004
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$3.53 |
Max. Negotiated Rate |
$5.14 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.85
|
Rate for Payer: Aetna of CA Government/Medicare |
$3.85
|
Rate for Payer: Cash Price |
$3.53
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.14
|
Rate for Payer: Health Smart Auto/Commercial |
$3.85
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.85
|
Rate for Payer: LLUH Dept of Risk Management WC |
$3.53
|
Rate for Payer: Multiplan Commercial |
$4.82
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
OP
|
$0.03
|
|
Service Code
|
NDC 0904052360
|
Hospital Charge Code |
901700029
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
OP
|
$0.03
|
|
Service Code
|
NDC 5789684101
|
Hospital Charge Code |
901700029
|
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 |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.02
|
|
Service Code
|
NDC 0904052372
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
OP
|
$0.03
|
|
Service Code
|
NDC 8770140741
|
Hospital Charge Code |
901700029
|
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 |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
Service Code
|
NDC 8770140741
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.04
|
|
Service Code
|
NDC 0904052361
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
Rate for Payer: Multiplan Commercial |
$0.03
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
OP
|
$0.04
|
|
Service Code
|
NDC 8770140739
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.03 |
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 |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
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 Commercial |
$0.03
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
Service Code
|
NDC 0904052360
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
Service Code
|
NDC 5789684101
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|