|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [103895]
|
Facility
|
IP
|
$541.63
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
1721197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$433.30 |
| Rate for Payer: Cash Price |
$243.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$433.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$324.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$406.22
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [103895]
|
Facility
|
OP
|
$541.63
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
1721197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$406.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$324.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$324.98
|
| Rate for Payer: Cash Price |
$243.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$324.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$324.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$406.22
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
IP
|
$607.71
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
NDG231988A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$334.24 |
| Max. Negotiated Rate |
$486.17 |
| Rate for Payer: Cash Price |
$273.47
|
| Rate for Payer: Cash Price |
$282.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$501.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$486.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$364.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$376.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$344.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$334.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$455.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$470.11
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
OP
|
$607.71
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
NDG231988A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$334.24 |
| Max. Negotiated Rate |
$455.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$364.63
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$376.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$364.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$376.09
|
| Rate for Payer: Cash Price |
$273.47
|
| Rate for Payer: Cash Price |
$282.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$364.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$376.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$376.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$364.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$334.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$344.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$470.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$455.78
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SOLUTION [11037]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$210.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.59
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SOLUTION [11037]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$224.79 |
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$210.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.59
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$224.79 |
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$224.79 |
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$210.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.59
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$224.79 |
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.54 |
| Max. Negotiated Rate |
$210.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.59
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.74
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
|
IP
|
$19,860.05
|
|
|
Service Code
|
NDC 50242-105-01
|
| Hospital Charge Code |
ERX225066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,923.03 |
| Max. Negotiated Rate |
$15,888.04 |
| Rate for Payer: Cash Price |
$8,937.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15,888.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$11,916.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,923.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14,895.04
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
|
OP
|
$19,860.05
|
|
|
Service Code
|
NDC 50242-105-01
|
| Hospital Charge Code |
ERX225066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,923.03 |
| Max. Negotiated Rate |
$14,895.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11,916.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11,916.03
|
| Rate for Payer: Cash Price |
$8,937.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$11,916.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11,916.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,923.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14,895.04
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
IP
|
$95.74
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
1780065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.66 |
| Max. Negotiated Rate |
$76.59 |
| Rate for Payer: Health Smart Auto/Commercial |
$57.44
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$71.80
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
OP
|
$95.74
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
1780065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.66 |
| Max. Negotiated Rate |
$71.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.44
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$71.80
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 45802-868-03
|
| Hospital Charge Code |
1713150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 43386-312-08
|
| Hospital Charge Code |
NDG24984B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 43386-312-08
|
| Hospital Charge Code |
NDG24984B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| 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: 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 Beech St/Commercial/PHCS |
$0.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 45802-868-03
|
| Hospital Charge Code |
1713150
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.01
|
| 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 Beech St/Commercial/PHCS |
$0.02
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 45802-868-66
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.48
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.84
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 9999-9321-54
|
| Hospital Charge Code |
1719218
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 45802-868-66
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.84
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 11523-7268-8
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.02
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-99
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.44
|
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