|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.20
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
OP
|
$479.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.54 |
| Max. Negotiated Rate |
$383.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$287.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$287.50
|
| Rate for Payer: Cash Price |
$263.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$383.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$287.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$287.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$263.54
|
| Rate for Payer: Multiplan Commercial |
$359.38
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
IP
|
$479.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.54 |
| Max. Negotiated Rate |
$383.34 |
| Rate for Payer: Cash Price |
$263.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$383.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$287.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$263.54
|
| Rate for Payer: Multiplan Commercial |
$359.38
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
IP
|
$472.43
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$259.84 |
| Max. Negotiated Rate |
$377.94 |
| Rate for Payer: Cash Price |
$259.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$377.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$283.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$259.84
|
| Rate for Payer: Multiplan Commercial |
$354.32
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
OP
|
$472.43
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$259.84 |
| Max. Negotiated Rate |
$377.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$283.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$283.46
|
| Rate for Payer: Cash Price |
$259.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$377.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$283.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$283.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$259.84
|
| Rate for Payer: Multiplan Commercial |
$354.32
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$59.25
|
|
|
Service Code
|
NDC 0904-7149-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.59 |
| Max. Negotiated Rate |
$47.40 |
| Rate for Payer: Cash Price |
$32.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.59
|
| Rate for Payer: Multiplan Commercial |
$44.44
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$59.25
|
|
|
Service Code
|
NDC 0904-7149-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.59 |
| Max. Negotiated Rate |
$47.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$35.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$35.55
|
| Rate for Payer: Cash Price |
$32.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$35.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.59
|
| Rate for Payer: Multiplan Commercial |
$44.44
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 72319-023-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 72319-023-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 0527-2133-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 0527-2133-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.00
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]
|
Facility
|
IP
|
$16.45
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$13.16 |
| Rate for Payer: Cash Price |
$9.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.05
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]
|
Facility
|
OP
|
$16.45
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$13.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.87
|
| Rate for Payer: Cash Price |
$9.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.05
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
|
OP
|
$36.21
|
|
|
Service Code
|
NDC 67457-665-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.92 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.73
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.92
|
| Rate for Payer: Multiplan Commercial |
$27.16
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
|
IP
|
$36.21
|
|
|
Service Code
|
NDC 67457-665-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.92 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.92
|
| Rate for Payer: Multiplan Commercial |
$27.16
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
|
IP
|
$38.12
|
|
|
Service Code
|
NDC 0085-4331-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$30.50 |
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$30.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.97
|
| Rate for Payer: Multiplan Commercial |
$28.59
|
|
