|
MUPIROCIN 2 % TOPICAL OINTMENT [10674]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 0093-1010-42
|
| 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
|
|
|
MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [196255]
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [196255]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 54643-5649-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.11
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 54643-5649-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
IP
|
$5.90
|
|
|
Service Code
|
NDC 54643-5647-0
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
OP
|
$5.77
|
|
|
Service Code
|
NDC 54643-5646-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.46
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$4.33
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
IP
|
$5.77
|
|
|
Service Code
|
NDC 54643-5646-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$4.33
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
OP
|
$5.90
|
|
|
Service Code
|
NDC 54643-5647-0
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.54
|
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION [23968]
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS J7519
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.85 |
| Max. Negotiated Rate |
$69.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$52.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$77.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$77.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$52.20
|
| Rate for Payer: Cash Price |
$71.27
|
| Rate for Payer: Cash Price |
$47.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$69.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$103.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$77.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$77.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$52.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.85
|
| Rate for Payer: Multiplan Commercial |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$97.18
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION [23968]
|
Facility
|
IP
|
$129.57
|
|
|
Service Code
|
HCPCS J7519
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.26 |
| Max. Negotiated Rate |
$103.66 |
| Rate for Payer: Cash Price |
$71.27
|
| Rate for Payer: Cash Price |
$47.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$69.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$103.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$77.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.85
|
| Rate for Payer: Multiplan Commercial |
$97.18
|
| Rate for Payer: Multiplan Commercial |
$65.25
|
|
|
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION [25005]
|
Facility
|
IP
|
$3.39
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
|
|
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION [25005]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
HCPCS J7517
|
| 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 EPO/HMO/POS/PPO |
$2.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.03
|
| 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: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.46
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| 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 |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| 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 |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
MYCOPHENOLATE MOFETIL 500 MG TABLET [21374]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
MYCOPHENOLATE MOFETIL 500 MG TABLET [21374]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE [38062]
|
Facility
|
IP
|
$8.95
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$6.71
|
|
|
MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE [38062]
|
Facility
|
OP
|
$8.95
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.37
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.68
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$6.71
|
|
|
MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE [38063]
|
Facility
|
IP
|
$9.13
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$7.30 |
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
|
|
MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE [38063]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 EPO/HMO/POS/PPO |
$5.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
|
|
NADOLOL 20 MG TABLET [5330]
|
Facility
|
IP
|
$6.19
|
|
|
Service Code
|
NDC 51079-812-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
|
|
NADOLOL 20 MG TABLET [5330]
|
Facility
|
OP
|
$6.19
|
|
|
Service Code
|
NDC 51079-812-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.71
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
|
