|
OXACILLIN 10 GRAM SOLUTION FOR INJECTION [5925]
|
Facility
|
IP
|
$140.16
|
|
|
Service Code
|
CPT J2700
|
| Hospital Charge Code |
ERX5925
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.09 |
| Max. Negotiated Rate |
$112.13 |
| Rate for Payer: Cash Price |
$63.07
|
| Rate for Payer: Cash Price |
$59.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$106.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$112.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$79.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$99.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$105.12
|
|
|
OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]
|
Facility
|
OP
|
$13.56
|
|
|
Service Code
|
CPT J2700
|
| Hospital Charge Code |
1753470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.46 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.41
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.41
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.46
|
|
|
OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
CPT J2700
|
| Hospital Charge Code |
1753470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.17
|
|
|
OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]
|
Facility
|
OP
|
$19.90
|
|
|
Service Code
|
CPT J2700
|
| Hospital Charge Code |
1753547
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$14.92 |
| Rate for Payer: Health Smart Auto/Commercial |
$11.94
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.94
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.27
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.82
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.92
|
|
|
OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]
|
Facility
|
IP
|
$28.03
|
|
|
Service Code
|
CPT J2700
|
| Hospital Charge Code |
1753547
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.42 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.34
|
|
|
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
1755749
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.19
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.80
|
|
|
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
1755749
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.80
|
|
|
OXALIPLATIN 100 MG INTRAVENOUS SOLUTION [23929]
|
Facility
|
OP
|
$636.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
ERX23929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$349.80 |
| Max. Negotiated Rate |
$477.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$381.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$381.60
|
| Rate for Payer: Cash Price |
$286.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$381.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$381.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$349.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$477.00
|
|
|
OXALIPLATIN 100 MG INTRAVENOUS SOLUTION [23929]
|
Facility
|
IP
|
$636.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
ERX23929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$349.80 |
| Max. Negotiated Rate |
$508.80 |
| Rate for Payer: Cash Price |
$286.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$508.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$381.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$349.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$477.00
|
|
|
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
NDG99610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
|
|
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
NDG99610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| 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: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.50
|
|
|
OXALIPLATIN 50 MG INTRAVENOUS SOLUTION [23928]
|
Facility
|
IP
|
$318.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
ERX23928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.90 |
| Max. Negotiated Rate |
$254.40 |
| Rate for Payer: Cash Price |
$143.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$254.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$190.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$174.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$238.50
|
|
|
OXALIPLATIN 50 MG INTRAVENOUS SOLUTION [23928]
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
ERX23928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.90 |
| Max. Negotiated Rate |
$238.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$190.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$190.80
|
| Rate for Payer: Cash Price |
$143.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$190.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$190.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$174.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$238.50
|
|
|
OXANDROLONE 10 MG TABLET [33826]
|
Facility
|
IP
|
$11.30
|
|
|
Service Code
|
NDC 0245-0272-06
|
| Hospital Charge Code |
1710982
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.22 |
| Max. Negotiated Rate |
$9.04 |
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.22
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.48
|
|
|
OXANDROLONE 10 MG TABLET [33826]
|
Facility
|
OP
|
$11.30
|
|
|
Service Code
|
NDC 0245-0272-06
|
| Hospital Charge Code |
1710982
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.22 |
| Max. Negotiated Rate |
$8.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.78
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.22
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.48
|
|
|
OXANDROLONE 2.5 MG TABLET [10803]
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 49884-301-01
|
| Hospital Charge Code |
1710935
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.89
|
|
|
OXANDROLONE 2.5 MG TABLET [10803]
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
NDC 0245-0271-11
|
| Hospital Charge Code |
1710935
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.00
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.50
|
|
|
OXANDROLONE 2.5 MG TABLET [10803]
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 49884-301-01
|
| Hospital Charge Code |
1710935
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$3.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.11
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.89
|
|
|
OXANDROLONE 2.5 MG TABLET [10803]
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
NDC 0245-0271-11
|
| Hospital Charge Code |
1710935
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.50
|
|
|
OXCARBAZEPINE 150 MG TABLET [27049]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 68084-845-11
|
| Hospital Charge Code |
1710905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
OXCARBAZEPINE 150 MG TABLET [27049]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 62756-183-88
|
| Hospital Charge Code |
1710905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
OXCARBAZEPINE 150 MG TABLET [27049]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 68084-845-01
|
| Hospital Charge Code |
1710905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
OXCARBAZEPINE 150 MG TABLET [27049]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 68462-137-01
|
| Hospital Charge Code |
1710905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
OXCARBAZEPINE 150 MG TABLET [27049]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 68084-845-11
|
| Hospital Charge Code |
1710905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
OXCARBAZEPINE 150 MG TABLET [27049]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 68462-137-01
|
| Hospital Charge Code |
1710905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
