|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
OP
|
$963.40
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$529.87 |
| Max. Negotiated Rate |
$770.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$578.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$578.04
|
| Rate for Payer: Cash Price |
$529.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$770.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$578.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$578.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$529.87
|
| Rate for Payer: Multiplan Commercial |
$722.55
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
IP
|
$963.40
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$529.87 |
| Max. Negotiated Rate |
$770.72 |
| Rate for Payer: Cash Price |
$529.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$770.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$578.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$529.87
|
| Rate for Payer: Multiplan Commercial |
$722.55
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0281020536
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.02
|
| 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 |
$0.02
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0281020536
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| 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 |
$0.02
|
|
|
TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 45802-390-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
|
|
TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
NDC 45802-390-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.68
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 16729-422-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 16729-422-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 0168-0416-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.25
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: Multiplan Commercial |
$4.07
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68462-534-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68462-534-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 0168-0416-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: Multiplan Commercial |
$4.07
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 0168-0416-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: Multiplan Commercial |
$4.07
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 0168-0416-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.25
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: Multiplan Commercial |
$4.07
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 45802-700-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 45802-700-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE [24914]
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE [24914]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.66
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
TACROLIMUS 0.5 MG/ML COMPOUNDED ORAL SUSPENSION [40840050]
|
Facility
|
IP
|
$3.62
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$2.71
|
|
|
TACROLIMUS 0.5 MG/ML COMPOUNDED ORAL SUSPENSION [40840050]
|
Facility
|
OP
|
$3.62
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$2.71
|
|
|
TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE [12933]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.98
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.83
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.66
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE [12933]
|
Facility
|
IP
|
$1.10
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
TACROLIMUS 5 MG CAPSULE, IMMEDIATE-RELEASE [12934]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$24.42
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$35.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$26.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$33.30
|
| Rate for Payer: Multiplan Commercial |
$2.62
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
TACROLIMUS 5 MG CAPSULE, IMMEDIATE-RELEASE [12934]
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$26.64
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$26.64
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$24.42
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$35.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$26.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$26.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$33.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.62
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
|
|
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION [12935]
|
Facility
|
IP
|
$306.03
|
|
|
Service Code
|
HCPCS J7525
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.32 |
| Max. Negotiated Rate |
$244.82 |
| Rate for Payer: Cash Price |
$168.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$244.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$183.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.32
|
| Rate for Payer: Multiplan Commercial |
$229.52
|
|
