|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$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: 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: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.43
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.38
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.43
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.43
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.38
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.43
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$181.10 |
| Max. Negotiated Rate |
$263.42 |
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$263.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$197.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.10
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$181.10 |
| Max. Negotiated Rate |
$263.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$197.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$197.56
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$263.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$197.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$197.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.10
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$181.10 |
| Max. Negotiated Rate |
$263.42 |
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$263.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$197.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.10
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$181.10 |
| Max. Negotiated Rate |
$263.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$197.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$197.56
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$263.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$197.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$197.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.10
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| 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 |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| 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 |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| 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 |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| 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 |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| 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 |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| 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 |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.52
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.52
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.70
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.49
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
|
