|
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION [14203]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J9390
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]
|
Facility
|
IP
|
$21.60
|
|
|
Service Code
|
HCPCS J9390
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Commercial |
$16.20
|
|
|
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]
|
Facility
|
OP
|
$21.60
|
|
|
Service Code
|
HCPCS J9390
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.96
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$12.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Commercial |
$16.20
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3504600106
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0904208560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3504600106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.03
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0904208560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
VITAMIN A ORAL SOLUTION (IV FORM) 50,000 UNITS/ML [4080447]
|
Facility
|
OP
|
$20.89
|
|
|
Service Code
|
NDC 9994080447
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.49 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.53
|
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$12.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.49
|
| Rate for Payer: Multiplan Commercial |
$15.67
|
|
|
VITAMIN A ORAL SOLUTION (IV FORM) 50,000 UNITS/ML [4080447]
|
Facility
|
IP
|
$20.89
|
|
|
Service Code
|
NDC 9994080447
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.49 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.49
|
| Rate for Payer: Multiplan Commercial |
$15.67
|
|
|
VITAMIN A PALMITATE 20,000 IU (6,000 MCG) PER 1 ML ORAL DROPS [4082303]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 1007847420
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
VITAMIN A PALMITATE 20,000 IU (6,000 MCG) PER 1 ML ORAL DROPS [4082303]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 1007847420
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
VITAMIN A PALMITATE 250 MCG-VIT C 50 MG-VIT D3 10 MCG/ML ORAL DROPS [228286]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0087040303
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
VITAMIN A PALMITATE 250 MCG-VIT C 50 MG-VIT D3 10 MCG/ML ORAL DROPS [228286]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0087040303
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 8770140725
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 4098521464
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.03
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0761043310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 8770140725
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 4098521464
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0761043310
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
VITAMIN A PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION [11641]
|
Facility
|
OP
|
$431.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$237.19 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$258.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$258.75
|
| Rate for Payer: Cash Price |
$194.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$345.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$258.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$258.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.19
|
| Rate for Payer: Multiplan Commercial |
$323.44
|
|
|
VITAMIN A PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION [11641]
|
Facility
|
IP
|
$431.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$237.19 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Cash Price |
$194.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$345.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$258.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.19
|
| Rate for Payer: Multiplan Commercial |
$323.44
|
|
|
VITAMIN B COMPLEX AND C NO.10-FOLIC ACID 900 MCG/5 ML ORAL LIQUID [32716]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 5485951608
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
VITAMIN B COMPLEX AND C NO.10-FOLIC ACID 900 MCG/5 ML ORAL LIQUID [32716]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 5485951608
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.03
|
|
|
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 5026885711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 5026885711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
