|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]
|
Facility
|
OP
|
$145.63
|
|
|
Service Code
|
NDC 24208-539-20
|
| Hospital Charge Code |
1740086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$109.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$87.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$87.38
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$87.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$87.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$109.22
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]
|
Facility
|
IP
|
$145.63
|
|
|
Service Code
|
NDC 24208-539-20
|
| Hospital Charge Code |
1740086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$116.50 |
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$116.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$87.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$109.22
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 63323-695-04
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 63323-691-30
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.55 |
| 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 |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.55
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 63323-691-30
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.55
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 0409-3307-03
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 0517-7504-25
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.08
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 0517-7504-25
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.08
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 63323-695-04
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 0409-3307-03
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
OP
|
$7.52
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1721126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.51
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.89
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.51
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.64
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.30
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1721126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.52 |
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.62
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1781092
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1744013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1744013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| 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 |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1781092
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
1710863
|
|
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
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
1710863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
1715996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
1715996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
1715121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$2.88 |
| 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 |
$1.73
|
| 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 Beech St/Commercial/PHCS |
$2.88
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
1715121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.88
|
|
|
ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 9994-0802-34
|
| Hospital Charge Code |
1715221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 9994-0802-34
|
| Hospital Charge Code |
1715221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
ACITRETIN 25 MG CAPSULE [13979]
|
Facility
|
OP
|
$18.46
|
|
|
Service Code
|
NDC 0115-1753-08
|
| Hospital Charge Code |
ERX13979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$13.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.08
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.84
|
|
