|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$27.01
|
|
|
Service Code
|
NDC 69097-999-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.86 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.86
|
| Rate for Payer: Multiplan Commercial |
$20.26
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.47 |
| Max. Negotiated Rate |
$64.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$48.51
|
| Rate for Payer: Aetna of CA Government/Medicare |
$48.51
|
| Rate for Payer: Cash Price |
$44.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$64.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$48.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.47
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.57 |
| Max. Negotiated Rate |
$27.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$20.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$20.26
|
| Rate for Payer: Cash Price |
$18.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$27.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$20.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.57
|
| Rate for Payer: Multiplan Commercial |
$25.32
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.57 |
| Max. Negotiated Rate |
$27.01 |
| Rate for Payer: Cash Price |
$18.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$27.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.57
|
| Rate for Payer: Multiplan Commercial |
$25.32
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$3.78
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.79
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.47
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.47
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$5.93
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.56
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$4.45
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.02
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$3.78
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$5.93
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$4.45
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
IP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$4.55
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
OP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.64
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$4.55
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.82
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 50268-652-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.54
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 50268-652-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 50268-652-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.54
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 50268-652-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
