|
HYDROMORPHONE PCA CLINICIAN BOLUS [4083524]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
HCPCS J1171
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.26
|
| 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 |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
HYDROMORPHONE PCA CLINICIAN BOLUS [4083524]
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
NDC 9994-0818-83
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.47
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
HYDROMORPHONE PCA CLINICIAN BOLUS [4083524]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
HCPCS J1171
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| 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 |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]
|
Facility
|
OP
|
$3.66
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$2.93 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.36
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.10
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$4.23
|
|
|
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]
|
Facility
|
IP
|
$2.26
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.01
|
| Rate for Payer: Multiplan Commercial |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [118734]
|
Facility
|
IP
|
$5.18
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.11
|
| 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 |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$3.88
|
|
|
HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [118734]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE [214315]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE [214315]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE - ADULT DISCRETE [40820494]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE - ADULT DISCRETE [40820494]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
HYDROMORPHONE (PF) 50 MG/50 ML IN NS IV PCA SYRINGE [40820378]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| 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: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
HYDROMORPHONE (PF) 50 MG/50 ML IN NS IV PCA SYRINGE [40820378]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
HYDROXOCOBALAMIN 1,000 MCG/ML INTRAMUSCULAR SOLUTION [3768]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS J3425
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.75
|
|
|
HYDROXOCOBALAMIN 1,000 MCG/ML INTRAMUSCULAR SOLUTION [3768]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J3425
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| 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 |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| 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 Commercial |
$0.75
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 68382-096-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$1.77
|
|
|
Service Code
|
NDC 50268-412-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$1.77
|
|
|
Service Code
|
NDC 50268-412-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 69238-1544-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$1.77
|
|
|
Service Code
|
NDC 50268-412-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 83980-001-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 69238-1544-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 68382-096-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$1.77
|
|
|
Service Code
|
NDC 50268-412-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 83980-001-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
