|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.58
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$1.98
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.11 |
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$1.98
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 75834-311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 75834-311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 75834-312-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| 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 |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| 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 |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 75834-312-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 42658-115-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 72205-368-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 72205-368-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 67877-491-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
