|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 64950-217-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 64950-217-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
ISONIAZID 50 MG/5 ML ORAL SOLUTION [4025]
|
Facility
|
IP
|
$0.85
|
|
|
Service Code
|
NDC 46287-009-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
|
|
ISONIAZID 50 MG/5 ML ORAL SOLUTION [4025]
|
Facility
|
OP
|
$0.85
|
|
|
Service Code
|
NDC 46287-009-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.51
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.51
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 0548-9502-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
OP
|
$16.80
|
|
|
Service Code
|
NDC 72485-113-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$13.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.08
|
| Rate for Payer: Cash Price |
$9.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$12.60
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
IP
|
$16.80
|
|
|
Service Code
|
NDC 72485-113-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$13.44 |
| Rate for Payer: Cash Price |
$9.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$12.60
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 0548-9502-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.80
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
OP
|
$16.80
|
|
|
Service Code
|
NDC 72485-113-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$13.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.08
|
| Rate for Payer: Cash Price |
$9.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$12.60
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
IP
|
$16.80
|
|
|
Service Code
|
NDC 72485-113-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$13.44 |
| Rate for Payer: Cash Price |
$9.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$12.60
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION FOR DRIPS [48110292]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 0548-9502-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.80
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION FOR DRIPS [48110292]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 0548-9502-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ISOSORBIDE 20 MG-HYDRALAZINE 37.5 MG TABLET [41893]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 52536-006-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
ISOSORBIDE 20 MG-HYDRALAZINE 37.5 MG TABLET [41893]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 24338-010-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.30
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
ISOSORBIDE 20 MG-HYDRALAZINE 37.5 MG TABLET [41893]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 52536-006-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
ISOSORBIDE 20 MG-HYDRALAZINE 37.5 MG TABLET [41893]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 24338-010-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 68084-082-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 68084-082-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 0143-1771-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 68001-374-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 50268-448-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 68001-374-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 72888-082-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 68084-082-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 50268-448-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
