|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
ERX37930
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
ERX37930
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
OP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$78.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$62.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$62.93
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$62.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.66
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
IP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$83.90 |
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.66
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
OP
|
$104.88
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX221907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$78.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$62.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$62.93
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$62.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.66
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
IP
|
$104.88
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX221907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$83.90 |
| Rate for Payer: Cigna of CA HMO/PPO |
$83.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.93
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.66
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 32909-167-55
|
| Hospital Charge Code |
NDG972961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.01
|
| 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 32909-167-55
|
| Hospital Charge Code |
NDG972961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 32909-121-07
|
| Hospital Charge Code |
NDG120621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 32909-121-07
|
| Hospital Charge Code |
NDG120621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 32909-750-03
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.01
|
| 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 32909-750-03
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION [23082]
|
Facility
|
OP
|
$5,155.45
|
|
|
Service Code
|
CPT J0480
|
| Hospital Charge Code |
1757346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,835.50 |
| Max. Negotiated Rate |
$3,866.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3,093.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3,093.27
|
| Rate for Payer: Cash Price |
$2,319.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,093.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3,093.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,835.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,866.59
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION [23082]
|
Facility
|
IP
|
$5,155.45
|
|
|
Service Code
|
CPT J0480
|
| Hospital Charge Code |
1757346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,835.50 |
| Max. Negotiated Rate |
$4,124.36 |
| Rate for Payer: Cash Price |
$2,319.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,124.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,093.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,835.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,866.59
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [117851]
|
Facility
|
OP
|
$188.48
|
|
|
Service Code
|
CPT J9030
|
| Hospital Charge Code |
1759920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.66 |
| Max. Negotiated Rate |
$141.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$113.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$113.09
|
| Rate for Payer: Cash Price |
$84.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$113.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$113.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$141.36
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [117851]
|
Facility
|
IP
|
$188.48
|
|
|
Service Code
|
CPT J9030
|
| Hospital Charge Code |
1759920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.66 |
| Max. Negotiated Rate |
$150.78 |
| Rate for Payer: Cash Price |
$84.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$150.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$113.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$141.36
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9999-9998-07
|
| Hospital Charge Code |
NDC408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
ERX408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.01
|
| 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
ERX408807
|
|
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
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
ERX408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
ERX408807
|
|
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
|
|
