|
BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 68382-720-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.60
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
|
|
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81454]
|
Facility
|
OP
|
$31.84
|
|
|
Service Code
|
NDC 0186-0370-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.51 |
| Max. Negotiated Rate |
$25.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.10
|
| Rate for Payer: Cash Price |
$17.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.51
|
| Rate for Payer: Multiplan Commercial |
$23.88
|
|
|
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81454]
|
Facility
|
IP
|
$31.84
|
|
|
Service Code
|
NDC 0186-0370-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.51 |
| Max. Negotiated Rate |
$25.47 |
| Rate for Payer: Cash Price |
$17.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.51
|
| Rate for Payer: Multiplan Commercial |
$23.88
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]
|
Facility
|
OP
|
$24.07
|
|
|
Service Code
|
NDC 0186-0372-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$19.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$13.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.24
|
| Rate for Payer: Multiplan Commercial |
$18.05
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]
|
Facility
|
IP
|
$24.07
|
|
|
Service Code
|
NDC 0186-0372-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$19.26 |
| Rate for Payer: Cash Price |
$13.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.24
|
| Rate for Payer: Multiplan Commercial |
$18.05
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]
|
Facility
|
IP
|
$24.11
|
|
|
Service Code
|
NDC 0186-0372-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$19.29 |
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.26
|
| Rate for Payer: Multiplan Commercial |
$18.08
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]
|
Facility
|
OP
|
$24.11
|
|
|
Service Code
|
NDC 0186-0372-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$19.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.47
|
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.26
|
| Rate for Payer: Multiplan Commercial |
$18.08
|
|
|
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| 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: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 50268-130-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.91
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 0185-0128-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 50268-130-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 69238-1489-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 0185-0128-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 42799-119-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 42799-119-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
BUMETANIDE 0.5 MG TABLET [9309]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 69238-1489-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 60687-384-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 60687-384-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 0185-0129-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 0832-0541-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 42799-120-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 60687-384-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 60687-384-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
BUMETANIDE 1 MG TABLET [9310]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 0185-0129-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
