|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
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 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
IP
|
$542.03
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.12 |
| Max. Negotiated Rate |
$433.62 |
| Rate for Payer: Cash Price |
$298.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$433.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$325.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.12
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
OP
|
$542.03
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.12 |
| Max. Negotiated Rate |
$433.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$325.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$325.22
|
| Rate for Payer: Cash Price |
$298.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$433.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$325.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$325.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.12
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
LEVALBUTEROL CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION (INTERMITTENT) [40856278]
|
Facility
|
IP
|
$6.43
|
|
|
Service Code
|
NDC 9940-8569-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
|
|
LEVALBUTEROL CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION (INTERMITTENT) [40856278]
|
Facility
|
OP
|
$6.43
|
|
|
Service Code
|
NDC 9940-8569-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.86
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
HCPCS J1953
|
| 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 |
$0.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| 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: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| 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 |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154436]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154436]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$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: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0904-7123-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| 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 |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| 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 |
$0.17
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0904-7123-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| 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 |
$0.17
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 65862-245-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-01
|
| 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
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-11
|
| 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
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-01
|
| 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
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-11
|
| 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
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 65862-245-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
