|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 59651-421-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 70710-1483-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 70710-1483-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 60687-100-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 42806-503-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 0527-1326-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 0527-1326-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994-0803-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 9994-0803-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
OP
|
$97.83
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.81 |
| Max. Negotiated Rate |
$78.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$58.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$58.70
|
| Rate for Payer: Cash Price |
$53.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$78.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$58.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.81
|
| Rate for Payer: Multiplan Commercial |
$73.37
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
IP
|
$97.83
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.81 |
| Max. Negotiated Rate |
$78.26 |
| Rate for Payer: Cash Price |
$53.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$78.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.81
|
| Rate for Payer: Multiplan Commercial |
$73.37
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 68084-215-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$2.78
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
NDC 50268-788-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
NDC 68084-215-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 68084-215-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$2.78
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
NDC 50268-788-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 68084-215-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.30
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 57237-042-90
|
| 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
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 63304-904-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 31722-704-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 0378-4275-77
|
| 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
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
NDC 50268-788-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 57237-042-90
|
| 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
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 31722-704-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
NDC 50268-788-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
|
