|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [120259]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 4110081163
|
| Hospital Charge Code |
NDG120259A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [120259]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 4110081122
|
| Hospital Charge Code |
NDG120259A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [120259]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140663
|
| Hospital Charge Code |
NDG120259B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [120259]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4110081122
|
| Hospital Charge Code |
NDG120259A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [120259]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 24385-070-26
|
| Hospital Charge Code |
NDG120259B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
|
|
VIT E-GLYCERIN-DIMETHICONE LOTION [115875]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 299391808
|
| Hospital Charge Code |
NDG115875B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
|
|
VIT E-GLYCERIN-DIMETHICONE LOTION [115875]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 299391808
|
| Hospital Charge Code |
NDG115875B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.01
|
| 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 |
$0.02
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
IP
|
$8.20
|
|
|
Service Code
|
NDC 0049-3160-44
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$6.56 |
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.15
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 65162-913-22
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$9.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.70
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.62
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
OP
|
$8.20
|
|
|
Service Code
|
NDC 0049-3160-44
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.92
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.15
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 65162-913-22
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.62
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]
|
Facility
|
IP
|
$179.93
|
|
|
Service Code
|
CPT J3465
|
| Hospital Charge Code |
1753462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.96 |
| Max. Negotiated Rate |
$143.94 |
| Rate for Payer: Cash Price |
$80.97
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$143.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$107.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$31.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$54.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$134.95
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT J3465
|
| Hospital Charge Code |
1753462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$43.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$25.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$107.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$43.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$107.96
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$80.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$107.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$107.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$25.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$134.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$31.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$54.00
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 0049-3180-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.35
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 65862-892-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.75
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 65862-892-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.75
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 68462-573-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.75
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 0049-3180-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.68
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.35
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 68462-573-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.75
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 27241-062-03
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.56
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 27241-062-03
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 68462-572-30
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.56
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 68462-572-30
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.95
|
|
|
VORINOSTAT 100 MG CAPSULE [77539]
|
Facility
|
OP
|
$150.10
|
|
|
Service Code
|
NDC 0006-0568-40
|
| Hospital Charge Code |
1711910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$112.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$90.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$90.06
|
| Rate for Payer: Cash Price |
$67.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$90.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$90.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$112.58
|
|
|
VORINOSTAT 100 MG CAPSULE [77539]
|
Facility
|
IP
|
$150.10
|
|
|
Service Code
|
NDC 0006-0568-40
|
| Hospital Charge Code |
1711910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$120.08 |
| Rate for Payer: Cash Price |
$67.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$90.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$112.58
|
|
