ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.06
|
|
Service Code
|
NDC 0904-6773-61
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Cash Price |
$0.04
|
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
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$0.06
|
|
Service Code
|
NDC 50580-458-11
|
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
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.04
|
|
Service Code
|
NDC 71399-8014-1
|
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
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$0.01
|
|
Service Code
|
NDC 57896-102-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.01 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.01
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$0.04
|
|
Service Code
|
NDC 71399-8014-1
|
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
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.01
|
|
Service Code
|
NDC 5789610110
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.01 |
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
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 |
$0.01
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.01
|
|
Service Code
|
NDC 57896-104-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.01 |
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
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 |
$0.01
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.06
|
|
Service Code
|
NDC 50580-458-11
|
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
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$0.06
|
|
Service Code
|
NDC 0904-6773-61
|
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 |
$0.04
|
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
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.01
|
|
Service Code
|
NDC 57896-102-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.01 |
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
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 |
$0.01
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$0.01
|
|
Service Code
|
NDC 0536-1327-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.01 |
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
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 |
$0.01
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$0.01
|
|
Service Code
|
NDC 0536-1327-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.01 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.01
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 57896-102-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
|
ACETAMINOPHEN 500 MG/50 ML (10 MG/ML) INTRAVENOUS SOLUTION [230835]
|
Facility
|
IP
|
$0.15
|
|
Service Code
|
HCPCS J0136
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.08 |
Max. Negotiated Rate |
$0.12 |
Rate for Payer: Cash Price |
$0.08
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
Rate for Payer: Multiplan Commercial |
$0.11
|
|
ACETAMINOPHEN 500 MG/50 ML (10 MG/ML) INTRAVENOUS SOLUTION [230835]
|
Facility
|
OP
|
$0.15
|
|
Service Code
|
HCPCS J0136
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.08 |
Max. Negotiated Rate |
$0.12 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
Rate for Payer: Cash Price |
$0.08
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
Rate for Payer: Multiplan Commercial |
$0.11
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
IP
|
$0.02
|
|
Service Code
|
NDC 57896-204-01
|
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
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.05
|
|
Service Code
|
NDC 50580-457-70
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.04 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.04
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 57896-201-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 57896-204-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
IP
|
$0.02
|
|
Service Code
|
NDC 57896-201-01
|
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
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 57896-201-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 57896-219-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 0904-6730-80
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.02 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
IP
|
$0.05
|
|
Service Code
|
NDC 50580-457-70
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.04 |
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.04
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
|
OP
|
$0.03
|
|
Service Code
|
NDC 0904-6730-60
|
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
|
|