|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$1.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.80
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$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
|
$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
|
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
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.56
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]
|
Facility
|
OP
|
$5.64
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.38
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.46
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$5.58
|
| Rate for Payer: Multiplan Commercial |
$4.23
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.09
|
| Rate for Payer: Multiplan Commercial |
$5.58
|
| Rate for Payer: Multiplan Commercial |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
AZITHROMYCIN 500 MG TABLET [17482]
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 65862-642-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.92
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
|
|
AZITHROMYCIN 500 MG TABLET [17482]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 68180-862-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
AZITHROMYCIN 500 MG TABLET [17482]
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 0069-3070-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.14
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.96
|
| Rate for Payer: Multiplan Commercial |
$2.68
|
|
|
AZITHROMYCIN 500 MG TABLET [17482]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 65862-642-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
|
|
AZITHROMYCIN 500 MG TABLET [17482]
|
Facility
|
IP
|
$3.57
|
|
|
Service Code
|
NDC 0069-3070-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.96
|
| Rate for Payer: Multiplan Commercial |
$2.68
|
|
|
AZITHROMYCIN 500 MG TABLET [17482]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 68180-862-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]
|
Facility
|
IP
|
$40.79
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.43 |
| Max. Negotiated Rate |
$32.63 |
| Rate for Payer: Cash Price |
$22.43
|
| Rate for Payer: Cash Price |
$16.63
|
| Rate for Payer: Cash Price |
$23.81
|
| Rate for Payer: Cash Price |
$19.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$32.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.82
|
| Rate for Payer: Multiplan Commercial |
$26.75
|
| Rate for Payer: Multiplan Commercial |
$22.68
|
| Rate for Payer: Multiplan Commercial |
$32.48
|
| Rate for Payer: Multiplan Commercial |
$30.59
|
|
|
AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]
|
Facility
|
OP
|
$30.24
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$24.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.47
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$25.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.47
|
| Rate for Payer: Cash Price |
$16.63
|
| Rate for Payer: Cash Price |
$23.81
|
| Rate for Payer: Cash Price |
$19.62
|
| Rate for Payer: Cash Price |
$22.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$32.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$25.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.62
|
| Rate for Payer: Multiplan Commercial |
$26.75
|
| Rate for Payer: Multiplan Commercial |
$30.59
|
| Rate for Payer: Multiplan Commercial |
$32.48
|
| Rate for Payer: Multiplan Commercial |
$22.68
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
|
OP
|
$80.34
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.19 |
| Max. Negotiated Rate |
$64.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$48.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$41.18
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$42.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$41.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$48.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$42.80
|
| Rate for Payer: Cash Price |
$37.75
|
| Rate for Payer: Cash Price |
$44.19
|
| Rate for Payer: Cash Price |
$39.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$64.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$54.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$41.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$42.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$42.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$41.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$48.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.19
|
| Rate for Payer: Multiplan Commercial |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$53.51
|
| Rate for Payer: Multiplan Commercial |
$60.26
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
|
IP
|
$80.34
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.19 |
| Max. Negotiated Rate |
$64.27 |
| Rate for Payer: Cash Price |
$44.19
|
| Rate for Payer: Cash Price |
$37.75
|
| Rate for Payer: Cash Price |
$39.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$64.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$54.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$41.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$42.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.24
|
| Rate for Payer: Multiplan Commercial |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$53.51
|
| Rate for Payer: Multiplan Commercial |
$60.26
|
|
|
AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]
|
Facility
|
IP
|
$181.28
|
|
|
Service Code
|
NDC 61958-0901-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.70 |
| Max. Negotiated Rate |
$145.02 |
| Rate for Payer: Cash Price |
$99.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$145.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$108.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.70
|
| Rate for Payer: Multiplan Commercial |
$135.96
|
|
|
AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]
|
Facility
|
OP
|
$181.28
|
|
|
Service Code
|
NDC 61958-0901-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.70 |
| Max. Negotiated Rate |
$145.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$108.77
|
| Rate for Payer: Aetna of CA Government/Medicare |
$108.77
|
| Rate for Payer: Cash Price |
$99.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$145.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$108.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$108.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.70
|
| Rate for Payer: Multiplan Commercial |
$135.96
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
|
IP
|
$37.06
|
|
|
Service Code
|
NDC 0574-4022-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$29.65 |
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$29.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.38
|
| Rate for Payer: Multiplan Commercial |
$27.80
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
|
OP
|
$37.06
|
|
|
Service Code
|
NDC 0574-4022-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$29.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$22.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$22.24
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$29.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$22.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.38
|
| Rate for Payer: Multiplan Commercial |
$27.80
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 45802-060-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 68001-477-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| 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 |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 45802-060-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 45802-060-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 45802-060-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
