|
BETHANECHOL ORAL SUSPENSION COMPOUND 1 MG/ML [4080248]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| 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 |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [38022]
|
Facility
|
IP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.49 |
| Max. Negotiated Rate |
$191.26 |
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$191.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$143.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [38022]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.49 |
| Max. Negotiated Rate |
$191.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$143.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$143.45
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$191.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$143.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$143.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVITREAL INJ [4080972]
|
Facility
|
IP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.49 |
| Max. Negotiated Rate |
$191.26 |
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$191.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$143.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVITREAL INJ [4080972]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.49 |
| Max. Negotiated Rate |
$191.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$143.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$143.45
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$191.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$143.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$143.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
NDC 9994-0810-93
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.49 |
| Max. Negotiated Rate |
$191.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$143.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$143.45
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$191.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$143.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$143.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
|
IP
|
$239.08
|
|
|
Service Code
|
NDC 9994-0810-93
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.49 |
| Max. Negotiated Rate |
$191.26 |
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$191.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$143.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
OP
|
$209.32
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.13 |
| Max. Negotiated Rate |
$167.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$125.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$125.59
|
| Rate for Payer: Cash Price |
$115.12
|
| Rate for Payer: Cash Price |
$115.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$167.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$125.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$125.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.13
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
IP
|
$209.32
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.13 |
| Max. Negotiated Rate |
$167.46 |
| Rate for Payer: Cash Price |
$115.12
|
| Rate for Payer: Cash Price |
$115.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$167.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$125.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.13
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS J0565
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.70 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.40
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$91.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.70
|
| Rate for Payer: Multiplan Commercial |
$85.50
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS J0565
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.70 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$91.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.70
|
| Rate for Payer: Multiplan Commercial |
$85.50
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 16729-023-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 41616-485-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 41616-485-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 47335-485-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 16729-023-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 47335-485-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L [121436]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-111-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L [121436]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-111-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BICARBONATE DIALYSIS SOLN WITHOUT CALCIUM NO15 POT 4 MEQ-MAG 1.2 MEQ/L [121260]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-114-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BICARBONATE DIALYSIS SOLN WITHOUT CALCIUM NO15 POT 4 MEQ-MAG 1.2 MEQ/L [121260]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-114-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.2 K 2 MEQ-CA 3.5 MEQ-MG 1 MEQ/L [120070]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS A4706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.2 K 2 MEQ-CA 3.5 MEQ-MG 1 MEQ/L [120070]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS A4706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.9 K 4 MEQ-CA 2.5 MEQ-MG 1.5 MEQ/L [100176]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-105-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.9 K 4 MEQ-CA 2.5 MEQ-MG 1.5 MEQ/L [100176]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-105-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
