|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
OP
|
$7.71
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$6.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.63
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.24
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$6.17 |
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.24
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
IP
|
$10.22
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$8.18 |
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: Multiplan Commercial |
$7.67
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
OP
|
$10.22
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$8.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.13
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: Multiplan Commercial |
$7.67
|
|
|
INSULIN GLULISINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [87889]
|
Facility
|
IP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$21.43 |
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: Multiplan Commercial |
$20.09
|
|
|
INSULIN GLULISINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [87889]
|
Facility
|
OP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$21.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.07
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: Multiplan Commercial |
$20.09
|
|
|
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP [10286]
|
Facility
|
OP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.21
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP [10286]
|
Facility
|
IP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
INSULIN LISPRO VIAL (HUMALOG, ADMELOG) 100 UNIT/ML SUBCUTANEOUS [17405]
|
Facility
|
IP
|
$15.69
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.63
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
| Rate for Payer: Multiplan Commercial |
$11.77
|
|
|
INSULIN LISPRO VIAL (HUMALOG, ADMELOG) 100 UNIT/ML SUBCUTANEOUS [17405]
|
Facility
|
OP
|
$11.77
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$9.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.06
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.06
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.63
|
| Rate for Payer: Multiplan Commercial |
$11.77
|
| Rate for Payer: Multiplan Commercial |
$8.83
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]
|
Facility
|
OP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.21
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]
|
Facility
|
IP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [225937]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 0338-0126-12
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [225937]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 0338-0126-12
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INSULIN REGULAR 1 UNIT/ML 5 ML IV SYRINGE [40820142]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 9940-8201-41
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
INSULIN REGULAR 1 UNIT/ML 5 ML IV SYRINGE [40820142]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 9940-8201-41
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
IP
|
$114.84
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.16 |
| Max. Negotiated Rate |
$91.87 |
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$91.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.16
|
| Rate for Payer: Multiplan Commercial |
$86.13
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
OP
|
$114.84
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.16 |
| Max. Negotiated Rate |
$91.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.90
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$91.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.16
|
| Rate for Payer: Multiplan Commercial |
$86.13
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]
|
Facility
|
IP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]
|
Facility
|
OP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.21
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F50.2
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F98.3
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F50.9
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F50.0
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F50.01
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
