|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-640-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-640-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 0054-0021-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 68084-640-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0904-6836-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0904-6836-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 50268-482-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-01
|
| 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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-01
|
| 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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 42799-605-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 50268-482-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 42799-605-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 72578-138-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 59651-691-01
|
| 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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-20
|
| 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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 50268-482-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 59651-691-01
|
| 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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-20
|
| 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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 50268-482-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
