|
LANTHANUM 1,000 MG CHEWABLE TABLET [43548]
|
Facility
|
OP
|
$6.67
|
|
|
Service Code
|
NDC 68180-821-10
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.00
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
|
|
LANTHANUM 1,000 MG CHEWABLE TABLET [43548]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
NDC 68180-821-10
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
|
|
LANTHANUM 1,000 MG CHEWABLE TABLET [43548]
|
Facility
|
OP
|
$6.67
|
|
|
Service Code
|
NDC 68180-821-47
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.00
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
|
|
LANTHANUM 1,000 MG CHEWABLE TABLET [43548]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
NDC 68180-821-47
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
|
|
LANTHANUM 500 MG CHEWABLE TABLET [39975]
|
Facility
|
OP
|
$14.41
|
|
|
Service Code
|
NDC 54092-252-45
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$11.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.65
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.93
|
| Rate for Payer: Multiplan Commercial |
$10.81
|
|
|
LANTHANUM 500 MG CHEWABLE TABLET [39975]
|
Facility
|
IP
|
$14.41
|
|
|
Service Code
|
NDC 54092-252-45
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$11.53 |
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.93
|
| Rate for Payer: Multiplan Commercial |
$10.81
|
|
|
LARONIDASE 2.9 MG/5 ML INTRAVENOUS SOLUTION [35779]
|
Facility
|
IP
|
$267.21
|
|
|
Service Code
|
HCPCS J1931
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.97 |
| Max. Negotiated Rate |
$213.77 |
| Rate for Payer: Cash Price |
$146.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$213.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$160.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.97
|
| Rate for Payer: Multiplan Commercial |
$200.41
|
|
|
LARONIDASE 2.9 MG/5 ML INTRAVENOUS SOLUTION [35779]
|
Facility
|
OP
|
$267.21
|
|
|
Service Code
|
HCPCS J1931
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.97 |
| Max. Negotiated Rate |
$213.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$160.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$160.33
|
| Rate for Payer: Cash Price |
$146.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$213.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$160.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$160.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.97
|
| Rate for Payer: Multiplan Commercial |
$200.41
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$5.14
|
|
|
Service Code
|
NDC 61314-547-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 24208-463-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$6.91 |
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 70069-421-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.43
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 59762-0333-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$8.64
|
|
|
Service Code
|
NDC 24208-463-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$6.91 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.18
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$6.48
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$5.14
|
|
|
Service Code
|
NDC 61314-547-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.08
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 70069-421-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 59762-0333-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
LECANEMAB-IRMB IN 0.9 % SODIUM CHLORIDE IV INFUSION [40820177]
|
Facility
|
IP
|
$152.88
|
|
|
Service Code
|
NDC 9940-8201-77
|
| Min. Negotiated Rate |
$84.08 |
| Max. Negotiated Rate |
$122.30 |
| Rate for Payer: Cash Price |
$84.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$122.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$91.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.08
|
| Rate for Payer: Multiplan Commercial |
$114.66
|
|
|
LECANEMAB-IRMB IN 0.9 % SODIUM CHLORIDE IV INFUSION [40820177]
|
Facility
|
OP
|
$152.88
|
|
|
Service Code
|
NDC 9940-8201-77
|
| Min. Negotiated Rate |
$84.08 |
| Max. Negotiated Rate |
$122.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$91.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$91.73
|
| Rate for Payer: Cash Price |
$84.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$122.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$91.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$91.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.08
|
| Rate for Payer: Multiplan Commercial |
$114.66
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| 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 |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| 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 |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.92
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.53
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| 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 |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| 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 |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
