|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0008
|
|
Hospital Revenue Code
|
126
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0010
|
|
Hospital Revenue Code
|
116
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0011
|
|
Hospital Revenue Code
|
136
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0009
|
|
Hospital Revenue Code
|
136
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0009
|
|
Hospital Revenue Code
|
126
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
INSULIN DEGLUDEC (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [223708]
|
Facility
|
OP
|
$40.67
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
NDG223708
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$30.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.40
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.50
|
|
|
INSULIN DEGLUDEC (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [223708]
|
Facility
|
IP
|
$40.67
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
NDG223708
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$32.54 |
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.50
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
OP
|
$35.05
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
1721115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$26.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.03
|
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.29
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
IP
|
$35.05
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
1721115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.29
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
IP
|
$34.07
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$27.26 |
| Rate for Payer: Cash Price |
$15.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$25.55
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
IP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$21.43 |
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.09
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
OP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.07
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.09
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
OP
|
$34.07
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$20.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$20.44
|
| Rate for Payer: Cash Price |
$15.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$20.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$25.55
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [225937]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 0338-0126-12
|
| Hospital Charge Code |
NDG225937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [225937]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 0338-0126-12
|
| Hospital Charge Code |
NDG225937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
IP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-01
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.16 |
| Max. Negotiated Rate |
$91.87 |
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$86.13
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
IP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-27
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.16 |
| Max. Negotiated Rate |
$91.87 |
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$86.13
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
OP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-01
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.16 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.90
|
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$86.13
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
OP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-27
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.16 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.90
|
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$86.13
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F98.21
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F50.8
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F98.29
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F50.2
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F98.3
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F50.9
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
