|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
|
OP
|
$145.87
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.23 |
| Max. Negotiated Rate |
$116.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$87.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$87.52
|
| Rate for Payer: Cash Price |
$80.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$116.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$87.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$87.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.23
|
| Rate for Payer: Multiplan Commercial |
$109.40
|
|
|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
|
IP
|
$145.87
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.23 |
| Max. Negotiated Rate |
$116.70 |
| Rate for Payer: Cash Price |
$80.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$116.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$87.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.23
|
| Rate for Payer: Multiplan Commercial |
$109.40
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
OP
|
$61.06
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$48.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.64
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$35.82
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$35.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$35.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$35.99
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cash Price |
$33.58
|
| Rate for Payer: Cash Price |
$32.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$35.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$35.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.58
|
| Rate for Payer: Multiplan Commercial |
$44.77
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
IP
|
$61.06
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$48.85 |
| Rate for Payer: Cash Price |
$33.58
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cash Price |
$32.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.99
|
| Rate for Payer: Multiplan Commercial |
$44.77
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
OP
|
$5.23
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.03
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$11.45
|
| Rate for Payer: Multiplan Commercial |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
IP
|
$5.23
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$11.45
|
| Rate for Payer: Multiplan Commercial |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
|
IP
|
$55.29
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$44.23 |
| Rate for Payer: Cash Price |
$30.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$44.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$41.47
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
|
OP
|
$55.29
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$44.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$33.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$33.17
|
| Rate for Payer: Cash Price |
$30.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$44.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$33.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$41.47
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-01
|
| 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 |
$0.05
|
| 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
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-01
|
| 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 |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| 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 |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| 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 |
$0.05
|
| 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
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0143-9837-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0093-1172-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0143-9837-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 57237-040-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 57237-040-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0093-1172-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| 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 |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| 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 |
$0.05
|
| 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
|
|
|
PENICILLIN V POTASSIUM 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9994-3000-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PENICILLIN V POTASSIUM 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9994-3000-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PENICILLIN V POTASSIUM 6.25 MG/ML (10,000 UNITS/ML) ORAL SOLN [4081500]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-00
|
| 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 |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 6.25 MG/ML (10,000 UNITS/ML) ORAL SOLN [4081500]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-00
|
| 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 |
$0.05
|
| 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
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
NDC 39822-3030-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.40 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$86.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$64.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
|
