|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 68001-382-00
|
| 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
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 68001-383-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 68382-800-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 68382-800-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 68001-383-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
LABETALOL 5 MG/ML CONT INFUSION ADULT (UNDILUTED) [4081288]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 0409-2267-54
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LABETALOL 5 MG/ML CONT INFUSION ADULT (UNDILUTED) [4081288]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 0409-2267-54
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LABETALOL 5 MG/ML CONT INFUSION PEDS (UNDILUTED) [40810372]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 0409-2267-54
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LABETALOL 5 MG/ML CONT INFUSION PEDS (UNDILUTED) [40810372]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 0409-2267-54
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$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: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION WRAP [40820329]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION WRAP [40820329]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| 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: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| 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: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
LABETALOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080288]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 9994-0802-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
LABETALOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080288]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 9994-0802-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 0904-7245-68
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 67877-734-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 0904-7245-68
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.48
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 67877-734-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9940-8201-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9940-8201-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 68462-940-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 69315-318-20
|
| 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
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 68462-940-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 69315-318-20
|
| 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
|
|
