|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 43547-349-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 68084-046-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 43547-349-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F98.3
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.0
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F98.3
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.9
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.01
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.2
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.8
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.01
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.2
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F98.21
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F98.21
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.9
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.02
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.02
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F98.29
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F98.29
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.0
|
|
Hospital Revenue Code
|
913
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
Partial Hospitalization, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev codes 912 or 913
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
ICD F50.8
|
|
Hospital Revenue Code
|
912
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Blue Shield of California Commercial |
$711.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$759.00
|
| Rate for Payer: Magellan Commercial |
$1,050.00
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$34.08 |
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.43
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$34.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$25.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.56
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$25.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.43
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$34.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$25.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.56
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$25.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.43
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$34.08 |
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.43
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
