|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 54643-5649-1
|
| Hospital Charge Code |
1765018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.21
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
OP
|
$5.02
|
|
|
Service Code
|
NDC 54643-5646-1
|
| Hospital Charge Code |
NDG117200A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.01
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.76
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 54643-5647-0
|
| Hospital Charge Code |
NDG117200B
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.08
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.85
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 54643-5647-0
|
| Hospital Charge Code |
NDG117200B
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.85
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
IP
|
$5.02
|
|
|
Service Code
|
NDC 54643-5646-1
|
| Hospital Charge Code |
NDG117200A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.76
|
|
|
MVI, PEDI NO.2 WITH VIT K 80 MG-400 UNIT-200 MCG INTRAVENOUS SOLUTION [197135]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 61703-421-53
|
| Hospital Charge Code |
ERX197135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$12.16 |
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.40
|
|
|
MVI, PEDI NO.2 WITH VIT K 80 MG-400 UNIT-200 MCG INTRAVENOUS SOLUTION [197135]
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 61703-421-53
|
| Hospital Charge Code |
ERX197135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.12
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.40
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION [23968]
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT J7519
|
| Hospital Charge Code |
1756520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.85 |
| Max. Negotiated Rate |
$69.60 |
| Rate for Payer: Cash Price |
$39.15
|
| Rate for Payer: Cash Price |
$58.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$77.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$97.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$65.25
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION [23968]
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT J7519
|
| Hospital Charge Code |
1756520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.85 |
| Max. Negotiated Rate |
$65.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$52.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$77.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$77.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$52.20
|
| Rate for Payer: Cash Price |
$39.15
|
| Rate for Payer: Cash Price |
$58.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$77.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$52.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$77.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$97.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$65.25
|
|
|
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSPENSION [25005]
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1715194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.03
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.54
|
|
|
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSPENSION [25005]
|
Facility
|
IP
|
$3.39
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1715194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.54
|
|
|
MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1711643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.33
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.46
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
|
MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1711643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
MYCOPHENOLATE MOFETIL 500 MG TABLET [21374]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1712219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
MYCOPHENOLATE MOFETIL 500 MG TABLET [21374]
|
Facility
|
OP
|
$21.59
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1712219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$16.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.95
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.95
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE [38062]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
CPT J7518
|
| Hospital Charge Code |
1712282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.89 |
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.93
|
|
|
MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE [38062]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
CPT J7518
|
| Hospital Charge Code |
1712282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.75
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.93
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.35
|
|
|
MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE [38063]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
CPT J7518
|
| Hospital Charge Code |
1712283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$7.11
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.34
|
|
|
MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE [38063]
|
Facility
|
OP
|
$15.81
|
|
|
Service Code
|
CPT J7518
|
| Hospital Charge Code |
1712283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.49
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.48
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.83
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.16
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$7.11
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.86
|
|
|
NADOLOL 20 MG TABLET [5330]
|
Facility
|
OP
|
$6.19
|
|
|
Service Code
|
NDC 51079-812-01
|
| Hospital Charge Code |
1711473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.71
|
| Rate for Payer: Cash Price |
$2.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
NADOLOL 20 MG TABLET [5330]
|
Facility
|
IP
|
$6.19
|
|
|
Service Code
|
NDC 51079-812-01
|
| Hospital Charge Code |
1711473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Cash Price |
$2.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
NADOLOL 40 MG TABLET [5331]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 69097-868-07
|
| Hospital Charge Code |
1710788
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
NADOLOL 40 MG TABLET [5331]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 69097-868-07
|
| Hospital Charge Code |
1710788
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
NADOLOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080308]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0803-08
|
| Hospital Charge Code |
1715268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
NADOLOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080308]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0803-08
|
| Hospital Charge Code |
1715268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
