|
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]
|
Facility
|
IP
|
$11.80
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
ERX97371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Cigna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Cash Price |
$5.31
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.49
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.85
|
|
|
VANCOMYCIN/BSS 2MG/0.2ML SYRINGE [4081576]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
NDC 9994-0815-76
|
| Hospital Charge Code |
NDG4081576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
VANCOMYCIN/BSS 2MG/0.2ML SYRINGE [4081576]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
NDC 9994-0815-76
|
| Hospital Charge Code |
NDG4081576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
VANCOMYCIN (BULK) 900 MCG/MG (NOT LESS THAN) POWDER [12217]
|
Facility
|
OP
|
$232.56
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
NDG12217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$174.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$139.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$139.54
|
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$139.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$139.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.91
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$174.42
|
|
|
VANCOMYCIN (BULK) 900 MCG/MG (NOT LESS THAN) POWDER [12217]
|
Facility
|
IP
|
$232.56
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
NDG12217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$186.05 |
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$186.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$139.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.91
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$174.42
|
|
|
VANCOMYCIN ORAL SOLUTION (IV FORM) 50 MG/ML [4080446]
|
Facility
|
OP
|
$1.03
|
|
|
Service Code
|
NDC 9994-0804-46
|
| Hospital Charge Code |
1715272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
VANCOMYCIN ORAL SOLUTION (IV FORM) 50 MG/ML [4080446]
|
Facility
|
IP
|
$1.03
|
|
|
Service Code
|
NDC 9994-0804-46
|
| Hospital Charge Code |
1715272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
VARENICLINE 0.5 MG TABLET [76444]
|
Facility
|
OP
|
$9.76
|
|
|
Service Code
|
NDC 0069-0468-56
|
| Hospital Charge Code |
1712341
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$7.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.86
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.32
|
|
|
VARENICLINE 0.5 MG TABLET [76444]
|
Facility
|
IP
|
$9.76
|
|
|
Service Code
|
NDC 0069-0468-56
|
| Hospital Charge Code |
1712341
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$7.81 |
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.32
|
|
|
VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [14757]
|
Facility
|
IP
|
$191.09
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
1721059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.10 |
| Max. Negotiated Rate |
$152.87 |
| Rate for Payer: Cash Price |
$85.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$114.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$143.32
|
|
|
VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [14757]
|
Facility
|
OP
|
$191.09
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
1721059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.10 |
| Max. Negotiated Rate |
$143.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$114.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$114.65
|
| Rate for Payer: Cash Price |
$85.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$114.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$114.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$143.32
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
OP
|
$97.20
|
|
|
Service Code
|
NDC 42023-164-01
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$58.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$58.32
|
| Rate for Payer: Cash Price |
$43.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$58.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.90
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
IP
|
$97.20
|
|
|
Service Code
|
NDC 42023-164-01
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Cash Price |
$43.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$77.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.90
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
IP
|
$97.20
|
|
|
Service Code
|
NDC 42023-164-10
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Cash Price |
$43.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$77.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.90
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
OP
|
$189.66
|
|
|
Service Code
|
NDC 43598-085-11
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.31 |
| Max. Negotiated Rate |
$142.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$113.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$113.80
|
| Rate for Payer: Cash Price |
$85.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$113.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$113.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$142.24
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
OP
|
$189.66
|
|
|
Service Code
|
NDC 43598-085-25
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.31 |
| Max. Negotiated Rate |
$142.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$113.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$113.80
|
| Rate for Payer: Cash Price |
$85.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$113.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$113.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$142.24
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
IP
|
$189.66
|
|
|
Service Code
|
NDC 43598-085-11
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.31 |
| Max. Negotiated Rate |
$151.73 |
| Rate for Payer: Cash Price |
$85.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$113.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$142.24
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
IP
|
$126.13
|
|
|
Service Code
|
NDC 70121-1642-5
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$100.90 |
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$100.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.60
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
IP
|
$189.66
|
|
|
Service Code
|
NDC 43598-085-25
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.31 |
| Max. Negotiated Rate |
$151.73 |
| Rate for Payer: Cash Price |
$85.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$113.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$142.24
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
IP
|
$126.13
|
|
|
Service Code
|
NDC 70121-1642-1
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$100.90 |
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$100.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.60
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
OP
|
$97.20
|
|
|
Service Code
|
NDC 42023-164-10
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$58.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$58.32
|
| Rate for Payer: Cash Price |
$43.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$58.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.90
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
OP
|
$126.13
|
|
|
Service Code
|
NDC 70121-1642-5
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$94.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$75.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$75.68
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$75.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.60
|
|
|
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [207969]
|
Facility
|
OP
|
$126.13
|
|
|
Service Code
|
NDC 70121-1642-1
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$94.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$75.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$75.68
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$75.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.60
|
|
|
VASOPRESSIN 20 UNITS/ML 1 ML VIAL - CODE [4080573]
|
Facility
|
OP
|
$97.20
|
|
|
Service Code
|
CPT J2598
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$58.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$58.32
|
| Rate for Payer: Cash Price |
$43.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$58.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.90
|
|
|
VASOPRESSIN 20 UNITS/ML 1 ML VIAL - CODE [4080573]
|
Facility
|
IP
|
$97.20
|
|
|
Service Code
|
CPT J2598
|
| Hospital Charge Code |
1757294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Cash Price |
$43.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$77.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.90
|
|
