|
TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]
|
Facility
|
OP
|
$3.72
|
|
|
Service Code
|
NDC 61314-643-05
|
| Hospital Charge Code |
1740185
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.79
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT [19769]
|
Facility
|
OP
|
$73.50
|
|
|
Service Code
|
NDC 0065-0644-35
|
| Hospital Charge Code |
1740222
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.42 |
| Max. Negotiated Rate |
$55.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$44.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$44.10
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$44.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.12
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT [19769]
|
Facility
|
IP
|
$73.50
|
|
|
Service Code
|
NDC 0065-0644-35
|
| Hospital Charge Code |
1740222
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.42 |
| Max. Negotiated Rate |
$58.80 |
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.12
|
|
|
TOBRAMYCIN 10 MG/ML NEBULIZER SOLUTION (IV FORM) [4080724]
|
Facility
|
OP
|
$3.68
|
|
|
Service Code
|
NDC 63323-305-02
|
| Hospital Charge Code |
1752037
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.21
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.76
|
|
|
TOBRAMYCIN 10 MG/ML NEBULIZER SOLUTION (IV FORM) [4080724]
|
Facility
|
IP
|
$3.68
|
|
|
Service Code
|
NDC 63323-305-02
|
| Hospital Charge Code |
1752037
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.76
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [11565]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1720422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$41.58
|
| Rate for Payer: Cash Price |
$45.09
|
| Rate for Payer: Cash Price |
$38.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$54.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$55.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$51.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$64.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$67.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$69.30
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [11565]
|
Facility
|
OP
|
$92.40
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1720422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.82 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$55.44
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$51.84
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$60.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$54.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$51.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$60.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$55.44
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$38.88
|
| Rate for Payer: Cash Price |
$41.58
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$45.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$51.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$54.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$55.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$55.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$51.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$54.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$60.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$69.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$67.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$64.80
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$10.82
|
|
|
Service Code
|
NDC 17478-340-38
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$8.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.49
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.12
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 43598-605-04
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.12
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$15.45
|
|
|
Service Code
|
NDC 0781-7171-56
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.27
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.59
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 43598-605-04
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.69
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.69
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.12
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
IP
|
$4.07
|
|
|
Service Code
|
NDC 65162-914-46
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.05
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
IP
|
$15.45
|
|
|
Service Code
|
NDC 0781-7171-84
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$12.36 |
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.59
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$15.45
|
|
|
Service Code
|
NDC 0781-7171-84
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.27
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.59
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
IP
|
$15.45
|
|
|
Service Code
|
NDC 0781-7171-56
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$12.36 |
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.59
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
IP
|
$10.82
|
|
|
Service Code
|
NDC 17478-340-38
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.12
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$4.07
|
|
|
Service Code
|
NDC 65162-914-46
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.44
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.05
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1752244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.66
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
NDG7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1752244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.66
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
NDG7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1757631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.89 |
| 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 |
$0.54
|
| 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1757631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
IP
|
$82.16
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
1740289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.19 |
| Max. Negotiated Rate |
$65.73 |
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$49.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$61.62
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
OP
|
$82.16
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
1740289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.19 |
| Max. Negotiated Rate |
$61.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$49.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$49.30
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$49.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$61.62
|
|
