|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$3.83
|
|
|
Service Code
|
NDC 63323-695-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
OP
|
$3.83
|
|
|
Service Code
|
NDC 63323-695-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.06 |
| 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 |
$2.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.06
|
| 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 Commercial |
$2.87
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
NDC 63323-695-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$3.28
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 0517-7504-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 0517-7504-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 0409-3307-03
|
| 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
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.89
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.44
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| 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: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$4.79
|
|
|
Service Code
|
NDC 63323-694-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.83 |
| 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: Cash Price |
$2.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
| Rate for Payer: Multiplan Commercial |
$3.59
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$4.79
|
|
|
Service Code
|
NDC 63323-694-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
| Rate for Payer: Multiplan Commercial |
$3.59
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 63323-694-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Cash Price |
$0.72
|
| 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
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 0517-7604-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.71
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 0517-7604-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.71
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 63323-690-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 63323-690-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 63323-690-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 0517-7604-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 0517-7604-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 63323-690-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| 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: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| 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: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 63323-694-41
|
| 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 |
$0.72
|
| 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
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.07
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| 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 Commercial |
$0.07
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| 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 |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| 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 Commercial |
$0.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.07 |
| 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 |
$2.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.07
|
| 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 Commercial |
$2.88
|
|
