|
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]
|
Facility
|
OP
|
$147.10
|
|
|
Service Code
|
NDC 67457-198-99
|
| Hospital Charge Code |
1737067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.90 |
| Max. Negotiated Rate |
$110.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$88.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$88.26
|
| Rate for Payer: Cash Price |
$66.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$88.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$88.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$110.32
|
|
|
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]
|
Facility
|
OP
|
$147.10
|
|
|
Service Code
|
NDC 67457-198-05
|
| Hospital Charge Code |
1737067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.90 |
| Max. Negotiated Rate |
$110.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$88.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$88.26
|
| Rate for Payer: Cash Price |
$66.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$88.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$88.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$110.32
|
|
|
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]
|
Facility
|
IP
|
$147.10
|
|
|
Service Code
|
NDC 67457-198-05
|
| Hospital Charge Code |
1737067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.90 |
| Max. Negotiated Rate |
$117.68 |
| Rate for Payer: Cash Price |
$66.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$88.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$110.32
|
|
|
RESLIZUMAB 10 MG/ML INTRAVENOUS SOLUTION [214073]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
NDC 59310-610-31
|
| Hospital Charge Code |
NDG214073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$100.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.50
|
|
|
RESLIZUMAB 10 MG/ML INTRAVENOUS SOLUTION [214073]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
NDC 59310-610-31
|
| Hospital Charge Code |
NDG214073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$75.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$75.60
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$75.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.50
|
|
|
RESP ONLY: HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION 30 ML [40810176]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
CPT J1644
|
| Hospital Charge Code |
1759630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| 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: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
RESP ONLY: HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION 30 ML [40810176]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
CPT J1644
|
| Hospital Charge Code |
1759630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]
|
Facility
|
IP
|
$87.48
|
|
|
Service Code
|
CPT J2791
|
| Hospital Charge Code |
1712616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.11 |
| Max. Negotiated Rate |
$69.98 |
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$43.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$65.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.17
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]
|
Facility
|
OP
|
$96.23
|
|
|
Service Code
|
CPT J2791
|
| Hospital Charge Code |
1712616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.93 |
| Max. Negotiated Rate |
$72.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.74
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$52.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$52.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.74
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$43.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$52.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$52.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.93
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$65.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.17
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 15,000 UNIT (3,000 MCG)/13 ML INJ. SOLN [70576]
|
Facility
|
IP
|
$501.41
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$275.78 |
| Max. Negotiated Rate |
$401.13 |
| Rate for Payer: Cash Price |
$225.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$401.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$300.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$275.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$376.06
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 15,000 UNIT (3,000 MCG)/13 ML INJ. SOLN [70576]
|
Facility
|
OP
|
$501.41
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$275.78 |
| Max. Negotiated Rate |
$376.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$300.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$300.85
|
| Rate for Payer: Cash Price |
$225.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$300.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$300.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$275.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$376.06
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 1,500 UNIT (300 MCG)/1.3 ML INJECT.SOLN [70575]
|
Facility
|
IP
|
$498.31
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.07 |
| Max. Negotiated Rate |
$398.65 |
| Rate for Payer: Cash Price |
$224.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$398.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$298.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$373.73
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 1,500 UNIT (300 MCG)/1.3 ML INJECT.SOLN [70575]
|
Facility
|
OP
|
$498.31
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.07 |
| Max. Negotiated Rate |
$373.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$298.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$298.99
|
| Rate for Payer: Cash Price |
$224.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$298.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$298.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$373.73
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 2,500 UNIT (500 MCG)/2.2 ML INJECT.SOLN [70573]
|
Facility
|
IP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.60 |
| Max. Negotiated Rate |
$395.05 |
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$395.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$296.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$271.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$370.36
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 2,500 UNIT (500 MCG)/2.2 ML INJECT.SOLN [70573]
|
Facility
|
OP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.60 |
| Max. Negotiated Rate |
$370.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$296.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$296.29
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$296.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$296.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$271.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$370.36
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN [70574]
|
Facility
|
IP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.60 |
| Max. Negotiated Rate |
$395.05 |
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$395.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$296.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$271.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$370.36
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN [70574]
|
Facility
|
OP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.60 |
| Max. Negotiated Rate |
$370.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$296.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$296.29
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$296.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$296.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$271.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$370.36
|
|
|
RIBAVIRIN 200 MG TABLET [11287]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 65862-207-68
|
| Hospital Charge Code |
ERX11287
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
RIBAVIRIN 200 MG TABLET [11287]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 65862-207-68
|
| Hospital Charge Code |
ERX11287
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985420195
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985420195
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 4329256000
|
| Hospital Charge Code |
1712617
|
|
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
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 1184571401
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 761003220
|
| Hospital Charge Code |
1712617
|
|
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: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 4329256000
|
| Hospital Charge Code |
1712617
|
|
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
|
|
