|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
|
OP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,928.45 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3,194.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3,194.67
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,194.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3,194.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,928.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,993.34
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
|
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,928.45 |
| Max. Negotiated Rate |
$4,259.56 |
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,259.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,194.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,928.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,993.34
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
|
IP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,385.13 |
| Max. Negotiated Rate |
$6,378.38 |
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,378.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4,783.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,385.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5,979.73
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
|
OP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,385.13 |
| Max. Negotiated Rate |
$5,979.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4,783.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4,783.78
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$4,783.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4,783.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,385.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5,979.73
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
|
IP
|
$4,063.93
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,235.16 |
| Max. Negotiated Rate |
$3,251.14 |
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,251.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,438.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,235.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,047.95
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
|
OP
|
$4,063.93
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,235.16 |
| Max. Negotiated Rate |
$3,047.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,438.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,438.36
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2,438.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,235.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,047.95
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
|
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
1720927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,928.45 |
| Max. Negotiated Rate |
$4,259.56 |
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,259.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,194.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,928.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,993.34
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
|
OP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
1720927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,928.45 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3,194.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3,194.67
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,194.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3,194.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,928.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,993.34
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
|
OP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,385.13 |
| Max. Negotiated Rate |
$5,979.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4,783.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4,783.78
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$4,783.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4,783.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,385.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5,979.73
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
|
IP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,385.13 |
| Max. Negotiated Rate |
$6,378.38 |
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,378.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4,783.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,385.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5,979.73
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.36
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
IP
|
$30.86
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.97 |
| Max. Negotiated Rate |
$24.69 |
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.14
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 69238-1615-3
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
OP
|
$30.86
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.97 |
| Max. Negotiated Rate |
$23.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.52
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.14
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 50383-025-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 69238-1615-3
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 50383-025-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.36
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.70
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
OP
|
$4.91
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.95
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.95
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.68
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
IP
|
$4.91
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.68
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 59746-307-32
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 59746-307-12
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 49884-321-55
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.13
|
|
