|
ATOMOXETINE 10 MG CAPSULE [34444]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 64980-373-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.64
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.52 |
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.64
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ATOMOXETINE 25 MG CAPSULE [34446]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60687-567-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.52 |
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 64980-376-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
IP
|
$7.59
|
|
|
Service Code
|
NDC 60687-326-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$5.69
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
IP
|
$7.59
|
|
|
Service Code
|
NDC 60687-326-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$5.69
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
OP
|
$7.59
|
|
|
Service Code
|
NDC 60687-326-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.55
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$5.69
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
OP
|
$7.59
|
|
|
Service Code
|
NDC 60687-326-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.55
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$5.69
|
|
|
ATOMOXETINE 40 MG CAPSULE [34447]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 64980-376-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 68084-097-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| 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 |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| 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 Commercial |
$0.33
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 68084-097-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.33
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 72205-022-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 72205-022-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0378-3950-77
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 60505-2578-9
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 68084-097-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.33
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0378-3950-77
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 60505-2578-9
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 68084-097-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| 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 |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| 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 Commercial |
$0.33
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 0904-6291-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 51079-209-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| 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 |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| 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 Commercial |
$0.33
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 68084-098-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 51079-209-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.33
|
|
