|
CALCITRIOL 0.5 MCG CAPSULE [9351]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 62756-968-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
CALCITRIOL 0.5 MCG CAPSULE [9351]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 0093-7353-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.33
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
CALCITRIOL 0.5 MCG CAPSULE [9351]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 0093-7353-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
CALCITRIOL 1 MCG/ML INTRAVENOUS SOLUTION [9348]
|
Facility
|
IP
|
$11.94
|
|
|
Service Code
|
HCPCS J0636
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$9.55 |
| Rate for Payer: Cash Price |
$6.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.57
|
| Rate for Payer: Multiplan Commercial |
$8.96
|
|
|
CALCITRIOL 1 MCG/ML INTRAVENOUS SOLUTION [9348]
|
Facility
|
OP
|
$11.94
|
|
|
Service Code
|
HCPCS J0636
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$9.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.16
|
| Rate for Payer: Cash Price |
$6.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.57
|
| Rate for Payer: Multiplan Commercial |
$8.96
|
|
|
CALCITRIOL 1 MCG/ML ORAL SOLUTION [16218]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 64980-447-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.20
|
| Rate for Payer: Cash Price |
$17.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
|
|
CALCITRIOL 1 MCG/ML ORAL SOLUTION [16218]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 64980-447-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Cash Price |
$17.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
|
|
CALCITRIOL 1 MCG/ML ORAL SOLUTION [16218]
|
Facility
|
OP
|
$10.88
|
|
|
Service Code
|
NDC 63304-241-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$5.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.98
|
| Rate for Payer: Multiplan Commercial |
$8.16
|
|
|
CALCITRIOL 1 MCG/ML ORAL SOLUTION [16218]
|
Facility
|
OP
|
$11.46
|
|
|
Service Code
|
NDC 0054-3120-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.88
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$8.60
|
|
|
CALCITRIOL 1 MCG/ML ORAL SOLUTION [16218]
|
Facility
|
IP
|
$10.88
|
|
|
Service Code
|
NDC 63304-241-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Cash Price |
$5.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.98
|
| Rate for Payer: Multiplan Commercial |
$8.16
|
|
|
CALCITRIOL 1 MCG/ML ORAL SOLUTION [16218]
|
Facility
|
IP
|
$11.46
|
|
|
Service Code
|
NDC 0054-3120-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$8.60
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770190081
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$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 Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770190081
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 24385-478-47
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$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 Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1007-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 68084-988-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 66553-004-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| 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 |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904-6412-92
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 68084-988-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| 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: Cash Price |
$0.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 24385-478-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904-6412-92
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 68084-988-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1007-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 66553-004-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.05
|
|
|
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 68084-988-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| 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: Cash Price |
$0.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
