BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM [106176]
|
Facility
|
IP
|
$2.67
|
|
Service Code
|
HCPCS J0572
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$1.47 |
Max. Negotiated Rate |
$2.14 |
Rate for Payer: Cash Price |
$1.47
|
Rate for Payer: Cash Price |
$1.87
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.14
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.71
|
Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
Rate for Payer: Multiplan Commercial |
$2.54
|
Rate for Payer: Multiplan Commercial |
$2.00
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
IP
|
$3.04
|
|
Service Code
|
HCPCS J0572
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$1.67 |
Max. Negotiated Rate |
$2.43 |
Rate for Payer: Cash Price |
$1.67
|
Rate for Payer: Cash Price |
$0.61
|
Rate for Payer: Cash Price |
$0.73
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.43
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
Rate for Payer: Health Smart Auto/Commercial |
$1.82
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
Rate for Payer: Multiplan Commercial |
$0.83
|
Rate for Payer: Multiplan Commercial |
$1.00
|
Rate for Payer: Multiplan Commercial |
$2.28
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
OP
|
$3.04
|
|
Service Code
|
HCPCS J0572
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$1.67 |
Max. Negotiated Rate |
$2.43 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.82
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.82
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
Rate for Payer: Cash Price |
$0.61
|
Rate for Payer: Cash Price |
$1.67
|
Rate for Payer: Cash Price |
$0.73
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.43
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
Rate for Payer: Health Smart Auto/Commercial |
$1.82
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.82
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
Rate for Payer: Multiplan Commercial |
$0.83
|
Rate for Payer: Multiplan Commercial |
$1.00
|
Rate for Payer: Multiplan Commercial |
$2.28
|
|
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]
|
Facility
|
IP
|
$64.43
|
|
Service Code
|
NDC 42858-750-40
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$35.44 |
Max. Negotiated Rate |
$51.54 |
Rate for Payer: Cash Price |
$35.44
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$51.54
|
Rate for Payer: Health Smart Auto/Commercial |
$38.66
|
Rate for Payer: LLUH Dept of Risk Management WC |
$35.44
|
Rate for Payer: Multiplan Commercial |
$48.32
|
|
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]
|
Facility
|
OP
|
$64.43
|
|
Service Code
|
NDC 42858-750-40
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$35.44 |
Max. Negotiated Rate |
$51.54 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$38.66
|
Rate for Payer: Aetna of CA Government/Medicare |
$38.66
|
Rate for Payer: Cash Price |
$35.44
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$51.54
|
Rate for Payer: Health Smart Auto/Commercial |
$38.66
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$38.66
|
Rate for Payer: LLUH Dept of Risk Management WC |
$35.44
|
Rate for Payer: Multiplan Commercial |
$48.32
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
IP
|
$4.78
|
|
Service Code
|
HCPCS J0574
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.63 |
Max. Negotiated Rate |
$3.82 |
Rate for Payer: Cash Price |
$2.63
|
Rate for Payer: Cash Price |
$2.25
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.26
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.82
|
Rate for Payer: Health Smart Auto/Commercial |
$2.87
|
Rate for Payer: Health Smart Auto/Commercial |
$2.45
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
Rate for Payer: Multiplan Commercial |
$3.06
|
Rate for Payer: Multiplan Commercial |
$3.58
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
OP
|
$4.08
|
|
Service Code
|
HCPCS J0574
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.24 |
Max. Negotiated Rate |
$3.26 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.45
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.87
|
Rate for Payer: Aetna of CA Government/Medicare |
$2.87
|
Rate for Payer: Aetna of CA Government/Medicare |
$2.45
|
Rate for Payer: Cash Price |
$2.63
|
Rate for Payer: Cash Price |
$2.25
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.26
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.82
|
Rate for Payer: Health Smart Auto/Commercial |
$2.45
|
Rate for Payer: Health Smart Auto/Commercial |
$2.87
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.45
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.87
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
Rate for Payer: Multiplan Commercial |
$3.58
|
Rate for Payer: Multiplan Commercial |
$3.06
|
|
BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]
|
Facility
|
IP
|
$16.34
|
|
Service Code
|
HCPCS J0592
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$8.99 |
Max. Negotiated Rate |
$13.07 |
Rate for Payer: Cash Price |
$8.99
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.07
|
Rate for Payer: Health Smart Auto/Commercial |
$9.80
|
Rate for Payer: LLUH Dept of Risk Management WC |
$8.99
|
Rate for Payer: Multiplan Commercial |
$12.26
|
|
BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]
|
Facility
|
OP
|
$16.34
|
|
Service Code
|
HCPCS J0592
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$8.99 |
Max. Negotiated Rate |
$13.07 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.80
|
Rate for Payer: Aetna of CA Government/Medicare |
$9.80
|
Rate for Payer: Cash Price |
$8.99
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.07
|
Rate for Payer: Health Smart Auto/Commercial |
$9.80
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.80
|
Rate for Payer: LLUH Dept of Risk Management WC |
$8.99
|
Rate for Payer: Multiplan Commercial |
$12.26
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]
|
Facility
|
OP
|
$0.64
|
|
Service Code
|
HCPCS J0571
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.35 |
Max. Negotiated Rate |
$0.51 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
Rate for Payer: Cash Price |
$0.35
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
Rate for Payer: Multiplan Commercial |
$0.48
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]
|
Facility
|
IP
|
$0.64
|
|
Service Code
|
HCPCS J0571
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.35 |
Max. Negotiated Rate |
$0.51 |
Rate for Payer: Cash Price |
$0.35
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
Rate for Payer: Multiplan Commercial |
$0.48
|
|
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]
|
Facility
|
IP
|
$4.20
|
|
Service Code
|
HCPCS J0571
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.31 |
Max. Negotiated Rate |
$3.36 |
Rate for Payer: Cash Price |
$2.31
|
Rate for Payer: Cash Price |
$0.53
|
Rate for Payer: Cash Price |
$1.10
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
Rate for Payer: Multiplan Commercial |
$0.72
|
Rate for Payer: Multiplan Commercial |
$1.50
|
Rate for Payer: Multiplan Commercial |
$3.15
|
|
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]
|
Facility
|
OP
|
$4.20
|
|
Service Code
|
HCPCS J0571
|
Hospital Charge Code |
901700054
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.31 |
Max. Negotiated Rate |
$3.36 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
Rate for Payer: Cash Price |
$0.53
|
Rate for Payer: Cash Price |
$2.31
|
Rate for Payer: Cash Price |
$1.10
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
Rate for Payer: Multiplan Commercial |
$0.72
|
Rate for Payer: Multiplan Commercial |
$1.50
|
Rate for Payer: Multiplan Commercial |
$3.15
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.80
|
|
Service Code
|
NDC 68001-309-00
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.44 |
Max. Negotiated Rate |
$0.64 |
Rate for Payer: Cash Price |
$0.44
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
Rate for Payer: Multiplan Commercial |
$0.60
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$2.12
|
|
Service Code
|
NDC 50268-143-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.17 |
Max. Negotiated Rate |
$1.70 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
Rate for Payer: Cash Price |
$1.17
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
Rate for Payer: Multiplan Commercial |
$1.59
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.80
|
|
Service Code
|
NDC 68001-309-00
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.44 |
Max. Negotiated Rate |
$0.64 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.48
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.48
|
Rate for Payer: Cash Price |
$0.44
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.48
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
Rate for Payer: Multiplan Commercial |
$0.60
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$2.12
|
|
Service Code
|
NDC 50268-143-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.17 |
Max. Negotiated Rate |
$1.70 |
Rate for Payer: Cash Price |
$1.17
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
Rate for Payer: Multiplan Commercial |
$1.59
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.86
|
|
Service Code
|
NDC 60505-0157-1
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.47 |
Max. Negotiated Rate |
$0.69 |
Rate for Payer: Cash Price |
$0.47
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
Rate for Payer: Multiplan Commercial |
$0.65
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.44
|
|
Service Code
|
NDC 23155-192-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.24 |
Max. Negotiated Rate |
$0.35 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
Rate for Payer: Cash Price |
$0.24
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
Rate for Payer: Multiplan Commercial |
$0.33
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.44
|
|
Service Code
|
NDC 23155-192-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.24 |
Max. Negotiated Rate |
$0.35 |
Rate for Payer: Cash Price |
$0.24
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
Rate for Payer: Multiplan Commercial |
$0.33
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$2.12
|
|
Service Code
|
NDC 50268-143-11
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.17 |
Max. Negotiated Rate |
$1.70 |
Rate for Payer: Cash Price |
$1.17
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
Rate for Payer: Multiplan Commercial |
$1.59
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.05
|
|
Service Code
|
NDC 0904-7530-60
|
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 |
$0.03
|
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 Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.04
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.86
|
|
Service Code
|
NDC 60505-0157-1
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.47 |
Max. Negotiated Rate |
$0.69 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
Rate for Payer: Cash Price |
$0.47
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
Rate for Payer: Multiplan Commercial |
$0.65
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$2.12
|
|
Service Code
|
NDC 50268-143-11
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.17 |
Max. Negotiated Rate |
$1.70 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
Rate for Payer: Cash Price |
$1.17
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
Rate for Payer: Multiplan Commercial |
$1.59
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.05
|
|
Service Code
|
NDC 0904-7530-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.04 |
Rate for Payer: Cash Price |
$0.03
|
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
|
|