|
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [4719]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [4719]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MAGNESIUM SULFATE 4 GRAM/50 ML (8 %) IN WATER INTRAVENOUS PIGGYBACK [4721]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
MAGNESIUM SULFATE 4 GRAM/50 ML (8 %) IN WATER INTRAVENOUS PIGGYBACK [4721]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.33
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.33
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 11068-01006
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 11068-01006
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 9994-0804-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 9994-0804-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 3877929822
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 78573-00081
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.72
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 78573-00081
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 3877929822
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.72
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-12
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0338-0357-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-12
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0338-0357-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| 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 |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| 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 |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MANNITOL 25 % INTRAVENOUS SOLUTION [4750]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
MANNITOL 25 % INTRAVENOUS SOLUTION [4750]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]
|
Facility
|
IP
|
$111.54
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.35 |
| Max. Negotiated Rate |
$89.23 |
| Rate for Payer: Cash Price |
$61.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$89.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$66.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.35
|
| Rate for Payer: Multiplan Commercial |
$83.66
|
|
