|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
1753536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0904-6353-61
|
| Hospital Charge Code |
1712271
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.40
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 65862-538-20
|
| Hospital Charge Code |
1712271
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0904-6353-61
|
| Hospital Charge Code |
1712271
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.40
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 65862-538-20
|
| Hospital Charge Code |
1712271
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-58
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-79
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-79
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-58
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
LEVONORGESTREL 17.5 MCG/24 HRS (5YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
OP
|
$1,322.04
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX216252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$727.12 |
| Max. Negotiated Rate |
$991.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$793.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$793.22
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$793.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$793.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$727.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$991.53
|
|
|
LEVONORGESTREL 17.5 MCG/24 HRS (5YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
IP
|
$1,322.04
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX216252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$727.12 |
| Max. Negotiated Rate |
$1,057.63 |
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,057.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$793.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$727.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$991.53
|
|
|
LEVONORGESTREL 20.4 MCG/24 HRS (8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
IP
|
$1,014.12
|
|
|
Service Code
|
CPT J7297
|
| Hospital Charge Code |
ERX205847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$557.77 |
| Max. Negotiated Rate |
$811.30 |
| Rate for Payer: Cash Price |
$456.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$811.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$608.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$557.77
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$760.59
|
|
|
LEVONORGESTREL 20.4 MCG/24 HRS (8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
OP
|
$1,014.12
|
|
|
Service Code
|
CPT J7297
|
| Hospital Charge Code |
ERX205847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$557.77 |
| Max. Negotiated Rate |
$760.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$608.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$608.47
|
| Rate for Payer: Cash Price |
$456.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$608.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$608.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$557.77
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$760.59
|
|
|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE [29280]
|
Facility
|
OP
|
$1,322.04
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
1712419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$727.12 |
| Max. Negotiated Rate |
$991.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$793.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$793.22
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$793.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$793.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$727.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$991.53
|
|
|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE [29280]
|
Facility
|
IP
|
$1,322.04
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
1712419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$727.12 |
| Max. Negotiated Rate |
$1,057.63 |
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,057.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$793.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$727.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$991.53
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$126.70
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.68 |
| Max. Negotiated Rate |
$101.36 |
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$101.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$95.02
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.37 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$90.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.05
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$113.40
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.37 |
| Max. Negotiated Rate |
$85.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.04
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.05
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$126.70
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.68 |
| Max. Negotiated Rate |
$101.36 |
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$101.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$95.02
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$126.70
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.68 |
| Max. Negotiated Rate |
$95.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$76.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$76.02
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$76.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$95.02
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$126.70
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.68 |
| Max. Negotiated Rate |
$95.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$76.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$76.02
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$76.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$95.02
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 72305-100-30
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0527-3284-46
|
| Hospital Charge Code |
1710605
|
|
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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 68180-969-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
