|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 51079-180-20
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 51079-180-20
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION [231219]
|
Facility
|
IP
|
$30,640.79
|
|
|
Service Code
|
NDC 79952-110-01
|
| Hospital Charge Code |
ERX231219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16,852.43 |
| Max. Negotiated Rate |
$24,512.63 |
| Rate for Payer: Cash Price |
$13,788.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24,512.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$18,384.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16,852.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22,980.59
|
|
|
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION [231219]
|
Facility
|
OP
|
$30,640.79
|
|
|
Service Code
|
NDC 79952-110-01
|
| Hospital Charge Code |
ERX231219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16,852.43 |
| Max. Negotiated Rate |
$22,980.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18,384.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18,384.47
|
| Rate for Payer: Cash Price |
$13,788.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$18,384.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18,384.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16,852.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22,980.59
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0904-6836-20
|
| Hospital Charge Code |
NDG42219
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.02
|
| 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 |
$0.03
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0904-6836-20
|
| Hospital Charge Code |
NDG42219
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-01
|
| Hospital Charge Code |
1710333
|
|
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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 42799-605-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-01
|
| Hospital Charge Code |
1710333
|
|
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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 42799-605-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-20
|
| Hospital Charge Code |
1710333
|
|
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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0378-2100-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-05
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0378-2100-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-20
|
| Hospital Charge Code |
1710333
|
|
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
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-05
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
LOPINAVIR-RITONAVIR 200 MG-50 MG TABLET [43391]
|
Facility
|
OP
|
$8.85
|
|
|
Service Code
|
NDC 31722-556-12
|
| Hospital Charge Code |
1712270
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$6.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.31
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.64
|
|
|
LOPINAVIR-RITONAVIR 200 MG-50 MG TABLET [43391]
|
Facility
|
IP
|
$8.85
|
|
|
Service Code
|
NDC 31722-556-12
|
| Hospital Charge Code |
1712270
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$7.08 |
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.64
|
|
|
LORATADINE 10 MG DISINTEGRATING TABLET [27512]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 46122-539-52
|
| Hospital Charge Code |
1710919
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
