|
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION [10529]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [105638]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [105638]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
MEPIVACAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [4081086]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
MEPIVACAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [4081086]
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
MERCAPTOPURINE 20 MG/ML ORAL SUSPENSION [206120]
|
Facility
|
IP
|
$17.20
|
|
|
Service Code
|
HCPCS S0108
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$13.76 |
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.46
|
| Rate for Payer: Multiplan Commercial |
$12.90
|
|
|
MERCAPTOPURINE 20 MG/ML ORAL SUSPENSION [206120]
|
Facility
|
OP
|
$17.20
|
|
|
Service Code
|
HCPCS S0108
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$13.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.32
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.46
|
| Rate for Payer: Multiplan Commercial |
$12.90
|
|
|
MERCAPTOPURINE 25 MG 1/2 TAB [192268]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS S0108
|
| Hospital Charge Code |
901700032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
MERCAPTOPURINE 25 MG 1/2 TAB [192268]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS S0108
|
| Hospital Charge Code |
901700032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
MERCAPTOPURINE 50 MG TABLET [10531]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
HCPCS S0108
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.43
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$2.85
|
|
|
MERCAPTOPURINE 50 MG TABLET [10531]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
HCPCS S0108
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$2.85
|
|
|
MEROPENEM 1 GM/100 ML NS ADMIXTURE KIT (ADSOK) [4085132]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9999-4085-13
|
| 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: Cash Price |
$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
|
|
|
MEROPENEM 1 GM/100 ML NS ADMIXTURE KIT (ADSOK) [4085132]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9999-4085-13
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$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
|
|
|
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
HCPCS J2185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.91
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.25
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.25
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.67
|
| Rate for Payer: Multiplan Commercial |
$5.17
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$5.31
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$18.64
|
|
|
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]
|
Facility
|
IP
|
$24.85
|
|
|
Service Code
|
HCPCS J2185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$19.88 |
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$5.31
|
| Rate for Payer: Multiplan Commercial |
$5.17
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
HCPCS J2185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$9.27
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
HCPCS J2185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.42
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$9.27
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION [219863]
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
HCPCS J2186
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.85 |
| Max. Negotiated Rate |
$213.60 |
| Rate for Payer: Cash Price |
$146.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$213.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$160.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.85
|
| Rate for Payer: Multiplan Commercial |
$200.25
|
|
|
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION [219863]
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
HCPCS J2186
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.85 |
| Max. Negotiated Rate |
$213.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$160.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$160.20
|
| Rate for Payer: Cash Price |
$146.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$213.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$160.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$160.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.85
|
| Rate for Payer: Multiplan Commercial |
$200.25
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
NDC 0378-9230-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.46
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.51
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$6.77
|
|
|
Service Code
|
NDC 59762-0118-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.06
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$5.08
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 0378-9230-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.51
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.21
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
