|
AZATHIOPRINE 25 MG 1/2 TAB [4081407]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
AZATHIOPRINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080245]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
AZATHIOPRINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080245]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
AZELASTINE 0.05 % EYE DROPS [28351]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 61314-308-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
|
|
AZELASTINE 0.05 % EYE DROPS [28351]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 61314-308-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.20
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
|
|
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 59651-214-30
|
| 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
|
|
|
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 60505-0833-5
|
| 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 |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 59651-214-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| 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: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 47335-779-91
|
| 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 |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| 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 |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 47335-779-91
|
| 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 |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 60505-0833-5
|
| 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 |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| 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 |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 0069-3140-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 42806-151-34
|
| 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
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 0093-2026-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 0069-3140-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 42806-151-34
|
| 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
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 0093-2026-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 50111-787-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 65862-641-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 59762-2198-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 65862-641-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50111-787-51
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 0781-8089-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
