|
TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]
|
Facility
|
IP
|
$71.26
|
|
|
Service Code
|
NDC 66302-310-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$57.01 |
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$42.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.19
|
| Rate for Payer: Multiplan Commercial |
$53.45
|
|
|
TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]
|
Facility
|
OP
|
$71.26
|
|
|
Service Code
|
NDC 66302-310-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$57.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$42.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$42.76
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$42.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$42.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.19
|
| Rate for Payer: Multiplan Commercial |
$53.45
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
OP
|
$178.15
|
|
|
Service Code
|
NDC 66302-325-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.98 |
| Max. Negotiated Rate |
$142.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$106.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$106.89
|
| Rate for Payer: Cash Price |
$97.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$142.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$106.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.98
|
| Rate for Payer: Multiplan Commercial |
$133.61
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
OP
|
$178.15
|
|
|
Service Code
|
NDC 66302-325-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.98 |
| Max. Negotiated Rate |
$142.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$106.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$106.89
|
| Rate for Payer: Cash Price |
$97.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$142.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$106.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.98
|
| Rate for Payer: Multiplan Commercial |
$133.61
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
IP
|
$178.15
|
|
|
Service Code
|
NDC 66302-325-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.98 |
| Max. Negotiated Rate |
$142.52 |
| Rate for Payer: Cash Price |
$97.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$142.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.98
|
| Rate for Payer: Multiplan Commercial |
$133.61
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
IP
|
$178.15
|
|
|
Service Code
|
NDC 66302-325-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.98 |
| Max. Negotiated Rate |
$142.52 |
| Rate for Payer: Cash Price |
$97.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$142.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.98
|
| Rate for Payer: Multiplan Commercial |
$133.61
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
IP
|
$356.31
|
|
|
Service Code
|
NDC 66302-350-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$195.97 |
| Max. Negotiated Rate |
$285.05 |
| Rate for Payer: Cash Price |
$195.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$285.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$213.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.97
|
| Rate for Payer: Multiplan Commercial |
$267.23
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
IP
|
$356.31
|
|
|
Service Code
|
NDC 66302-350-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$195.97 |
| Max. Negotiated Rate |
$285.05 |
| Rate for Payer: Cash Price |
$195.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$285.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$213.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.97
|
| Rate for Payer: Multiplan Commercial |
$267.23
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
OP
|
$356.31
|
|
|
Service Code
|
NDC 66302-350-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$195.97 |
| Max. Negotiated Rate |
$285.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$213.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$213.79
|
| Rate for Payer: Cash Price |
$195.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$285.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$213.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$213.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.97
|
| Rate for Payer: Multiplan Commercial |
$267.23
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
OP
|
$356.31
|
|
|
Service Code
|
NDC 66302-350-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$195.97 |
| Max. Negotiated Rate |
$285.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$213.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$213.79
|
| Rate for Payer: Cash Price |
$195.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$285.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$213.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$213.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.97
|
| Rate for Payer: Multiplan Commercial |
$267.23
|
|
|
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION [32934]
|
Facility
|
IP
|
$725.79
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$399.18 |
| Max. Negotiated Rate |
$580.63 |
| Rate for Payer: Cash Price |
$399.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$580.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$435.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$399.18
|
| Rate for Payer: Multiplan Commercial |
$544.34
|
|
|
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION [32934]
|
Facility
|
OP
|
$725.79
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$399.18 |
| Max. Negotiated Rate |
$580.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$435.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$435.47
|
| Rate for Payer: Cash Price |
$399.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$580.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$435.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$435.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$399.18
|
| Rate for Payer: Multiplan Commercial |
$544.34
|
|
|
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION [32931]
|
Facility
|
OP
|
$76.40
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.02 |
| Max. Negotiated Rate |
$61.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$45.84
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$41.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$45.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$41.26
|
| Rate for Payer: Cash Price |
$42.02
|
| Rate for Payer: Cash Price |
$37.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$61.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$55.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$41.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$41.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$45.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.82
|
| Rate for Payer: Multiplan Commercial |
$57.30
|
| Rate for Payer: Multiplan Commercial |
$51.57
|
|
|
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION [32931]
|
Facility
|
IP
|
$76.40
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.02 |
| Max. Negotiated Rate |
$61.12 |
| Rate for Payer: Cash Price |
$42.02
|
| Rate for Payer: Cash Price |
$37.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$55.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$61.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$41.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.82
|
| Rate for Payer: Multiplan Commercial |
$51.57
|
| Rate for Payer: Multiplan Commercial |
$57.30
|
|
|
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION [32932]
|
Facility
|
IP
|
$181.45
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$145.16 |
| Rate for Payer: Cash Price |
$99.80
|
| Rate for Payer: Cash Price |
$105.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$152.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$145.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$108.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$114.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.05
|
| Rate for Payer: Multiplan Commercial |
$143.25
|
| Rate for Payer: Multiplan Commercial |
$136.09
|
|
|
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION [32932]
|
Facility
|
OP
|
$181.45
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$145.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$108.87
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$114.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$108.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$114.60
|
| Rate for Payer: Cash Price |
$99.80
|
| Rate for Payer: Cash Price |
$105.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$145.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$152.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$108.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$114.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$108.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$114.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: Multiplan Commercial |
$136.09
|
| Rate for Payer: Multiplan Commercial |
$143.25
|
|
|
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION [32933]
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$199.59 |
| Max. Negotiated Rate |
$290.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$217.74
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$206.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$217.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$206.28
|
| Rate for Payer: Cash Price |
$199.59
|
| Rate for Payer: Cash Price |
$189.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$290.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$275.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$206.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$217.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$217.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$206.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.59
|
| Rate for Payer: Multiplan Commercial |
$272.18
|
| Rate for Payer: Multiplan Commercial |
$257.85
|
|
|
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION [32933]
|
Facility
|
IP
|
$343.80
|
|
|
Service Code
|
HCPCS J3285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.09 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: Cash Price |
$189.09
|
| Rate for Payer: Cash Price |
$199.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$290.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$275.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$206.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$217.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.59
|
| Rate for Payer: Multiplan Commercial |
$257.85
|
| Rate for Payer: Multiplan Commercial |
$272.18
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
IP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Cash Price |
$18.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Commercial |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
OP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$18.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Commercial |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
IP
|
$35.34
|
|
|
Service Code
|
NDC 68462-792-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.44 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Cash Price |
$19.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.44
|
| Rate for Payer: Multiplan Commercial |
$26.50
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
OP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$18.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Commercial |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
IP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Cash Price |
$18.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Commercial |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
OP
|
$35.34
|
|
|
Service Code
|
NDC 68462-792-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.44 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.20
|
| Rate for Payer: Cash Price |
$19.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.44
|
| Rate for Payer: Multiplan Commercial |
$26.50
|
|
|
TRETINOIN MICROSPHERES 0.1 % TOPICAL GEL [19468]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 0187-5140-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$16.80 |
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$15.75
|
|
