|
KETOROLAC 10 MG TABLET [10371]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 31722-686-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
KETOROLAC 10 MG TABLET [10371]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 0378-1134-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
|
|
KETOROLAC 10 MG TABLET [10371]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 0093-0314-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
|
|
KETOROLAC 10 MG TABLET [10371]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 31722-686-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| 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 |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
KETOROLAC 10 MG TABLET [10371]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
NDC 0093-0314-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.77
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.77
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
|
|
KETOROLAC 15 MG/ML INJECTION SOLUTION [22472]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.90
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.17
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
KETOROLAC 15 MG/ML INJECTION SOLUTION [22472]
|
Facility
|
IP
|
$3.61
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]
|
Facility
|
OP
|
$6.84
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.37
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.70
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]
|
Facility
|
IP
|
$6.84
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
|
|
KETOROLAC 30 MG/ML INJECTION. [4082473]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.37
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.26
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.10
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
|
|
KETOROLAC 30 MG/ML INJECTION. [4082473]
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
|
|
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION [91349]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION [91349]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 72485-617-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 72485-617-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 76385-106-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.69 |
| 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 |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.69
|
| 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 |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
NDC 76385-106-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
|
|
KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [153474]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.60
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
|
|
KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [153474]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.36
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
|
|
KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [121541]
|
Facility
|
IP
|
$11.98
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.59
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
|
|
KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [121541]
|
Facility
|
OP
|
$11.98
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.19
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.59
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
|
Facility
|
IP
|
$498.77
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$274.32 |
| Max. Negotiated Rate |
$399.02 |
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$399.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$299.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.32
|
| Rate for Payer: Multiplan Commercial |
$374.08
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
|
Facility
|
OP
|
$498.77
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$274.32 |
| Max. Negotiated Rate |
$399.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$299.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$299.26
|
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$399.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$299.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$299.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.32
|
| Rate for Payer: Multiplan Commercial |
$374.08
|
|
