|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 60687-736-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| 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 |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| 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 Commercial |
$0.20
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 65862-560-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 65862-560-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 65862-560-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.51 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.51
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 60687-767-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 60687-767-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.19
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.51 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.37
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.51
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.19
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.51 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.51
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 60687-767-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.19
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.19
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.51 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.37
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.51
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.19
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 60687-767-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.19
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$19.50
|
|
|
Service Code
|
HCPCS J2440
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.72 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Commercial |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$17.49
|
| Rate for Payer: Multiplan Commercial |
$16.88
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
HCPCS J2440
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.99
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.99
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.67
|
| Rate for Payer: Multiplan Commercial |
$17.49
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: Multiplan Commercial |
$16.88
|
| Rate for Payer: Multiplan Commercial |
$18.64
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION [222465]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0338-0502-06
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| 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 Commercial |
$0.06
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION [222465]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0338-0502-06
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.06
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION [224619]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4500-00
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
