|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
IP
|
$148.62
|
|
|
Service Code
|
NDC 66302-325-01
|
| Hospital Charge Code |
ERX205152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.74 |
| Max. Negotiated Rate |
$118.90 |
| Rate for Payer: Cash Price |
$66.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$118.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$89.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$111.46
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
OP
|
$148.62
|
|
|
Service Code
|
NDC 66302-325-01
|
| Hospital Charge Code |
ERX205152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.74 |
| Max. Negotiated Rate |
$111.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$89.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$89.17
|
| Rate for Payer: Cash Price |
$66.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$89.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$89.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$111.46
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
IP
|
$297.23
|
|
|
Service Code
|
NDC 66302-350-10
|
| Hospital Charge Code |
ERX218793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$163.48 |
| Max. Negotiated Rate |
$237.78 |
| Rate for Payer: Cash Price |
$133.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$237.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$178.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$222.92
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
IP
|
$297.23
|
|
|
Service Code
|
NDC 66302-350-01
|
| Hospital Charge Code |
ERX218793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$163.48 |
| Max. Negotiated Rate |
$237.78 |
| Rate for Payer: Cash Price |
$133.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$237.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$178.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$222.92
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
OP
|
$297.23
|
|
|
Service Code
|
NDC 66302-350-01
|
| Hospital Charge Code |
ERX218793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$163.48 |
| Max. Negotiated Rate |
$222.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$178.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$178.34
|
| Rate for Payer: Cash Price |
$133.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$178.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$178.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$222.92
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
OP
|
$297.23
|
|
|
Service Code
|
NDC 66302-350-10
|
| Hospital Charge Code |
ERX218793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$163.48 |
| Max. Negotiated Rate |
$222.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$178.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$178.34
|
| Rate for Payer: Cash Price |
$133.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$178.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$178.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$222.92
|
|
|
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION [32934]
|
Facility
|
IP
|
$725.79
|
|
|
Service Code
|
CPT J3285
|
| Hospital Charge Code |
NDG32934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$399.18 |
| Max. Negotiated Rate |
$580.63 |
| Rate for Payer: Cash Price |
$326.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$580.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$435.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$399.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$544.34
|
|
|
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION [32934]
|
Facility
|
OP
|
$725.79
|
|
|
Service Code
|
CPT J3285
|
| Hospital Charge Code |
NDG32934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$399.18 |
| Max. Negotiated Rate |
$544.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$435.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$435.47
|
| Rate for Payer: Cash Price |
$326.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$435.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$435.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$399.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$544.34
|
|
|
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION [32932]
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT J3285
|
| Hospital Charge Code |
NDG32932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.05 |
| Max. Negotiated Rate |
$152.80 |
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Cash Price |
$81.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$145.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$108.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$114.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$143.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$136.09
|
|
|
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION [32932]
|
Facility
|
OP
|
$181.45
|
|
|
Service Code
|
CPT J3285
|
| Hospital Charge Code |
NDG32932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$136.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$108.87
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$114.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$114.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$108.87
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Cash Price |
$81.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$114.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$108.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$108.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$114.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$136.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$143.25
|
|
|
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION [32933]
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
CPT J3285
|
| Hospital Charge Code |
NDG32933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$199.60 |
| Max. Negotiated Rate |
$272.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$217.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$217.74
|
| Rate for Payer: Cash Price |
$163.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$217.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$217.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$272.18
|
|
|
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION [32933]
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
CPT J3285
|
| Hospital Charge Code |
NDG32933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$199.60 |
| Max. Negotiated Rate |
$290.32 |
| Rate for Payer: Cash Price |
$163.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$217.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$272.18
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
IP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-21
|
| Hospital Charge Code |
1711646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Cash Price |
$14.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
IP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-11
|
| Hospital Charge Code |
1711646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Cash Price |
$14.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
OP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-21
|
| Hospital Charge Code |
1711646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$24.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$14.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
IP
|
$35.34
|
|
|
Service Code
|
NDC 68462-792-01
|
| Hospital Charge Code |
1711646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.44 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.50
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
OP
|
$33.03
|
|
|
Service Code
|
NDC 68084-075-11
|
| Hospital Charge Code |
1711646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$24.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$14.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$24.77
|
|
|
TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE [16005]
|
Facility
|
OP
|
$35.34
|
|
|
Service Code
|
NDC 68462-792-01
|
| Hospital Charge Code |
1711646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.44 |
| Max. Negotiated Rate |
$26.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.20
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.50
|
|
|
TRIAMCINOLONE 9 MG-MOXIFLOX 0.6 MG/0.6 ML IN WATER(PF)INTRAOCULAR SUSP [221760]
|
Facility
|
OP
|
$30.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG221760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.36
|
| Rate for Payer: Cash Price |
$13.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.95
|
|
|
TRIAMCINOLONE 9 MG-MOXIFLOX 0.6 MG/0.6 ML IN WATER(PF)INTRAOCULAR SUSP [221760]
|
Facility
|
IP
|
$30.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG221760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$24.48 |
| Rate for Payer: Cash Price |
$13.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.95
|
|
|
TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 45802-063-36
|
| Hospital Charge Code |
1743435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0168-0003-80
|
| Hospital Charge Code |
1743435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 33342-327-80
|
| Hospital Charge Code |
1743435
|
|
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
|
|
|
TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0168-0003-80
|
| Hospital Charge Code |
1743435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 45802-063-36
|
| Hospital Charge Code |
1743435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
