|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]
|
Facility
|
OP
|
$293.26
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
NDG14678
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.29 |
| Max. Negotiated Rate |
$219.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$175.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$175.96
|
| Rate for Payer: Cash Price |
$131.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$175.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$175.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$219.94
|
|
|
UREA 10 % LOTION [19779]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 5898060880
|
| Hospital Charge Code |
NDG19779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
UREA 10 % LOTION [19779]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 5898060880
|
| Hospital Charge Code |
NDG19779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
UREA 15 GRAM ORAL POWDER PACKET [218764]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 6253000011
|
| Hospital Charge Code |
ERX218764
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.15 |
| 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: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
UREA 15 GRAM ORAL POWDER PACKET [218764]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 6253000011
|
| Hospital Charge Code |
ERX218764
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 884044904
|
| Hospital Charge Code |
NDG19776B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 536110945
|
| Hospital Charge Code |
NDG19776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 536110945
|
| Hospital Charge Code |
NDG19776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 884044904
|
| Hospital Charge Code |
NDG19776B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$2.58
|
|
|
Service Code
|
NDC 68001-377-00
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.94
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.28
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$2.58
|
|
|
Service Code
|
NDC 68001-377-00
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.94
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.28
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.15 |
| 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: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.15 |
| 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: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$7.50
|
|
|
Service Code
|
NDC 42806-503-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.62
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$7.50
|
|
|
Service Code
|
NDC 42806-503-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.62
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$8.98
|
|
|
Service Code
|
NDC 0904-6221-06
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$7.18 |
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.74
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 59651-421-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.71
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 0527-1326-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.12
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 59651-421-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.71
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$9.20
|
|
|
Service Code
|
NDC 50268-796-11
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Cash Price |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.90
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 70710-1483-1
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
