|
CAPMATINIB 150 MG TABLET [228060]
|
Facility
|
IP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0709-56
|
| Hospital Charge Code |
ERX228060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$127.15 |
| Max. Negotiated Rate |
$184.94 |
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$138.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$173.38
|
|
|
CAPMATINIB 200 MG TABLET [228061]
|
Facility
|
IP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0716-56
|
| Hospital Charge Code |
ERX228061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$127.15 |
| Max. Negotiated Rate |
$184.94 |
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$138.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$173.38
|
|
|
CAPMATINIB 200 MG TABLET [228061]
|
Facility
|
OP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0716-56
|
| Hospital Charge Code |
ERX228061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$127.15 |
| Max. Negotiated Rate |
$173.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$138.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$138.71
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$138.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$138.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$173.38
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM [1350]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0536-2525-25
|
| Hospital Charge Code |
1743536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM [1350]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0536-2525-25
|
| Hospital Charge Code |
1743536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM [9399]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1118-25
|
| Hospital Charge Code |
NDG9399A
|
|
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
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM [9399]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1118-25
|
| Hospital Charge Code |
NDG9399A
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 0143-1171-01
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.92
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-11
|
| Hospital Charge Code |
1711381
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-21
|
| Hospital Charge Code |
1711381
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 69292-522-01
|
| Hospital Charge Code |
1711381
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 69292-522-01
|
| Hospital Charge Code |
1711381
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-11
|
| Hospital Charge Code |
1711381
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-21
|
| Hospital Charge Code |
1711381
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 0143-1171-01
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.92
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 60687-315-11
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.11
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.39
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 60687-315-21
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.39
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 69292-524-01
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 0781-8061-01
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 0781-8061-01
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 69292-524-01
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.95
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 60687-315-11
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.39
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 60687-315-21
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.11
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.39
|
|
|
CAPTOPRIL 50 MG TABLET [9403]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 0781-8075-01
|
| Hospital Charge Code |
1712017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.26
|
|
|
CAPTOPRIL 50 MG TABLET [9403]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 0781-8075-01
|
| Hospital Charge Code |
1712017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.26
|
|
