|
MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$66.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$66.92
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$66.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.35
|
| Rate for Payer: Multiplan Commercial |
$83.66
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 50268-522-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 60687-775-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 50268-522-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 50268-522-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 50268-522-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 60687-775-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 59746-121-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 16571-661-01
|
| 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
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| 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 |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| 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 |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| 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 |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| 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 |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 59746-121-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 16571-661-01
|
| 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
|
|
|
MECOBALAMIN (VITAMIN B12) 5,000 MCG DISINTEGRATING TABLET [196848]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 4009310109
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| 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 |
$0.16
|
|
|
MECOBALAMIN (VITAMIN B12) 5,000 MCG DISINTEGRATING TABLET [196848]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 4009310109
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.17
|
| 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 |
$0.16
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F98.21
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F50.82
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F50.9
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F50.01
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F50.2
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F50.02
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F98.29
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
MEDIUM CHAIN TRIGLYCERIDES (MCT) 14 GRAM-120 KCAL/15 ML ORAL OIL [227248]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 4009311257
|
| 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
|
|
