|
SENNOSIDES 8.6 MG TABLET [11349]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904-7252-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| 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 |
$0.02
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 71399-0027-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 69618-069-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 57237-301-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 57896-472-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 71399-0027-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 69618-069-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 57896-472-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [15168]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 57237-301-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 60687-253-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 60687-253-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 68180-353-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 65862-013-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 69097-835-02
|
| 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
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 60687-253-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 68180-353-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 60687-253-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 69097-835-02
|
| 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
|
|
|
SERTRALINE 100 MG TABLET [11350]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 65862-013-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE [28011]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 59762-0067-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE [28011]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 71093-143-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE [28011]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 64980-409-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE [28011]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 59762-0067-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE [28011]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 64980-409-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE [28011]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 71093-143-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
