|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
IP
|
$209.32
|
|
|
Service Code
|
NDC 55513-206-01
|
| Hospital Charge Code |
NDG225272A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.13 |
| Max. Negotiated Rate |
$167.46 |
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$156.99
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
OP
|
$209.32
|
|
|
Service Code
|
NDC 55513-206-01
|
| Hospital Charge Code |
NDG225272A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.13 |
| Max. Negotiated Rate |
$156.99 |
| 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 |
$94.19
|
| 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 Beech St/Commercial/PHCS |
$156.99
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
OP
|
$209.32
|
|
|
Service Code
|
NDC 55513-207-01
|
| Hospital Charge Code |
NDG225272B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.13 |
| Max. Negotiated Rate |
$156.99 |
| 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 |
$94.19
|
| 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 Beech St/Commercial/PHCS |
$156.99
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
IP
|
$209.32
|
|
|
Service Code
|
NDC 55513-207-01
|
| Hospital Charge Code |
NDG225272B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.13 |
| Max. Negotiated Rate |
$167.46 |
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$156.99
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT J0565
|
| Hospital Charge Code |
NDG216412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.70 |
| Max. Negotiated Rate |
$85.50 |
| 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 |
$51.30
|
| 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 Beech St/Commercial/PHCS |
$85.50
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT J0565
|
| Hospital Charge Code |
NDG216412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.70 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Cigna of CA HMO/PPO |
$91.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.40
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.50
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 41616-485-83
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 0904-6019-46
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 16729-023-10
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.68
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 16729-023-10
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| 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 |
$0.41
|
| 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 Beech St/Commercial/PHCS |
$0.68
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 41616-485-83
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.45 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0904-6019-46
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
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 |
1771296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$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 |
1771296
|
|
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: 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 Beech St/Commercial/PHCS |
$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 |
NDG121260
|
|
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: 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 Beech St/Commercial/PHCS |
$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 |
NDG121260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$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
|
CPT A4706
|
| Hospital Charge Code |
NDG120070
|
|
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: 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 Beech St/Commercial/PHCS |
$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
|
CPT A4706
|
| Hospital Charge Code |
NDG120070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$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 |
1771276
|
|
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: 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 Beech St/Commercial/PHCS |
$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 |
1771276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.01
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
|
IP
|
$151.81
|
|
|
Service Code
|
NDC 61958-2501-1
|
| Hospital Charge Code |
ERX221141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$83.50 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Cash Price |
$68.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$121.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$91.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$113.86
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
|
OP
|
$151.81
|
|
|
Service Code
|
NDC 61958-2501-1
|
| Hospital Charge Code |
ERX221141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$83.50 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$91.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$91.09
|
| Rate for Payer: Cash Price |
$68.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$91.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$91.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$113.86
|
|
|
BIMATOPROST 0.01 % EYE DROPS [105410]
|
Facility
|
IP
|
$114.92
|
|
|
Service Code
|
NDC 0023-3205-03
|
| Hospital Charge Code |
NDG105410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$91.94 |
| Rate for Payer: Cash Price |
$51.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$86.19
|
|
|
BIMATOPROST 0.01 % EYE DROPS [105410]
|
Facility
|
OP
|
$114.92
|
|
|
Service Code
|
NDC 0023-3205-03
|
| Hospital Charge Code |
NDG105410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$86.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.95
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.95
|
| Rate for Payer: Cash Price |
$51.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$86.19
|
|
|
BIOTIN 5 MG CAPSULE [9277]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 39413012
|
| Hospital Charge Code |
1712339
|
|
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
|
|
