|
ACITRETIN 25 MG CAPSULE [13979]
|
Facility
|
OP
|
$18.46
|
|
|
Service Code
|
NDC 0115-1753-08
|
| Hospital Charge Code |
ERX13979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$13.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.08
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.84
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0574-0521-74
|
| Hospital Charge Code |
1719162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0574-0521-74
|
| Hospital Charge Code |
1719162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| 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 |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 66689-201-08
|
| Hospital Charge Code |
1719161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0574-0521-76
|
| Hospital Charge Code |
1719161
|
|
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
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 66689-201-08
|
| Hospital Charge Code |
1719161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0574-0521-76
|
| Hospital Charge Code |
1719161
|
|
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
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1715057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.54
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1715057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
ACYCLOVIR 200 MG CAPSULE [8969]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1711380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
ACYCLOVIR 200 MG CAPSULE [8969]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1711380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1711675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1711675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 72578-082-01
|
| Hospital Charge Code |
1743351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.62
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.27
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 65162-835-94
|
| Hospital Charge Code |
1743351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 65162-835-94
|
| Hospital Charge Code |
1743351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 72578-082-01
|
| Hospital Charge Code |
1743351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.27
|
|
|
ACYCLOVIR 800 MG TABLET [8972]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1711515
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
ACYCLOVIR 800 MG TABLET [8972]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
1711515
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
ERX8974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.05
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
ERX8974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.24
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.05
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
IP
|
$2.26
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
NDG23128A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.70
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
NDG23128B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.58
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
NDG23128B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.58
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
OP
|
$2.26
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
NDG23128A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.36
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.36
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.01
|
|
