|
LAMIVUDINE 150 MG-ZIDOVUDINE 300 MG TABLET [21810]
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
NDC 31722-506-60
|
| Hospital Charge Code |
1710907
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.00
|
|
|
LAMIVUDINE 150 MG-ZIDOVUDINE 300 MG TABLET [21810]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 31722-506-60
|
| Hospital Charge Code |
1710907
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.60
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.00
|
|
|
LAMIVUDINE-ZIDOVUDINE ORAL SOLUTION COMPOUND [4080404]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 9994-0804-04
|
| Hospital Charge Code |
1715309
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
LAMIVUDINE-ZIDOVUDINE ORAL SOLUTION COMPOUND [4080404]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 9994-0804-04
|
| Hospital Charge Code |
1715309
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 69918-370-30
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.78
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
IP
|
$9.73
|
|
|
Service Code
|
NDC 49884-486-54
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.30
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
IP
|
$9.08
|
|
|
Service Code
|
NDC 43598-552-30
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$7.26 |
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.81
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
OP
|
$9.08
|
|
|
Service Code
|
NDC 43598-552-30
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$6.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.45
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.81
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
OP
|
$9.73
|
|
|
Service Code
|
NDC 49884-486-11
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$7.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.30
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
IP
|
$9.73
|
|
|
Service Code
|
NDC 49884-486-11
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.30
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 69918-370-30
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.83
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.78
|
|
|
LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]
|
Facility
|
OP
|
$9.73
|
|
|
Service Code
|
NDC 49884-486-54
|
| Hospital Charge Code |
1712436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$7.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.30
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 68382-008-01
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 29300-112-01
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 68382-008-01
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 68084-319-11
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.10
|
| 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 Beech St/Commercial/PHCS |
$0.17
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 51672-4131-1
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 68084-319-11
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.17
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 68084-319-01
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.17
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 51672-4131-1
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 29300-112-01
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 68084-319-01
|
| Hospital Charge Code |
1711639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.10
|
| 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 Beech St/Commercial/PHCS |
$0.17
|
|
|
LAMOTRIGINE 150 MG TABLET [14266]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 29300-113-16
|
| Hospital Charge Code |
1711640
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
LAMOTRIGINE 150 MG TABLET [14266]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 68382-009-14
|
| Hospital Charge Code |
1711640
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
LAMOTRIGINE 150 MG TABLET [14266]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 51672-4132-4
|
| Hospital Charge Code |
1711640
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.08
|
|
