|
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
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$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: 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
|
$2.50
|
|
|
Service Code
|
NDC 50742-182-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 50742-182-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| 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
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.99
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
OP
|
$27.67
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.22 |
| Max. Negotiated Rate |
$22.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.28
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Cash Price |
$15.22
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
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 |
$15.84
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$15.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.22
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
OP
|
$22.74
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$18.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.64
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.67
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$50.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$50.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.72
|
| Rate for Payer: Cash Price |
$11.62
|
| Rate for Payer: Cash Price |
$17.16
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.90
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$67.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$50.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$50.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.20
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$17.05
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
IP
|
$21.12
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.62 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Cash Price |
$11.62
|
| Rate for Payer: Cash Price |
$17.16
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.90
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$67.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$50.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.51
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$17.05
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
OP
|
$103.43
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.89 |
| Max. Negotiated Rate |
$82.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$62.06
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$63.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$63.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$62.06
|
| Rate for Payer: Cash Price |
$56.89
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$82.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$84.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$63.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$62.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$63.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.89
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$79.20
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
IP
|
$105.60
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.08 |
| Max. Negotiated Rate |
$84.48 |
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Cash Price |
$56.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$82.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$84.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$63.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.08
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$79.20
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
IP
|
$10.56
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.34
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.13
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 69315-184-01
|
| 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
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 69315-184-01
|
| 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
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$470.45 |
| Max. Negotiated Rate |
$684.29 |
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$684.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$513.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$470.45
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$470.45 |
| Max. Negotiated Rate |
$684.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$513.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$513.22
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$684.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$513.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$513.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$470.45
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$470.45 |
| Max. Negotiated Rate |
$684.29 |
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$684.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$513.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$470.45
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
|
