|
LACOSAMIDE 150 MG TABLET [96970]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 31722-814-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
LACOSAMIDE 150 MG TABLET [96970]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 31722-814-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION [96972]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION [96972]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
LACOSAMIDE 200 MG TABLET [96971]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 60687-698-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.34
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
LACOSAMIDE 200 MG TABLET [96971]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 60687-698-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.34
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
LACOSAMIDE 200 MG TABLET [96971]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 60687-698-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
LACOSAMIDE 200 MG TABLET [96971]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 60687-698-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
LACOSAMIDE 50 MG TABLET [96968]
|
Facility
|
IP
|
$2.36
|
|
|
Service Code
|
NDC 60687-676-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.77
|
|
|
LACOSAMIDE 50 MG TABLET [96968]
|
Facility
|
IP
|
$2.36
|
|
|
Service Code
|
NDC 60687-676-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.77
|
|
|
LACOSAMIDE 50 MG TABLET [96968]
|
Facility
|
OP
|
$2.36
|
|
|
Service Code
|
NDC 60687-676-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.42
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.77
|
|
|
LACOSAMIDE 50 MG TABLET [96968]
|
Facility
|
OP
|
$2.36
|
|
|
Service Code
|
NDC 60687-676-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.42
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.77
|
|
|
LACTATED RINGERS INTRAVENOUS SOLUTION [4318]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
LACTATED RINGERS INTRAVENOUS SOLUTION [4318]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
LACTATED RINGERS IV BOLUS [400296]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: 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
|
|
|
LACTATED RINGERS IV BOLUS [400296]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$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
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE [27974]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 4910040007
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE [27974]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 4910040007
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE WRAP [4081924]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 4910040009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE WRAP [4081924]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 4910040007
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE WRAP [4081924]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 4910040009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE WRAP [4081924]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 4910040021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE WRAP [4081924]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 4910040021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE WRAP [4081924]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 4910040007
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
LACTOBACILLUS RHAMNOSUS GG 5 BILLION CELL ORAL POWDER PACKET [205489]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 4910040008
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
