|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
HCPCS J9045
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.31
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| 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: Aetna of CA Government/Medicare |
$0.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS J9045
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 81298-5010-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$43.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$43.20
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$306.23 |
| Rate for Payer: Cash Price |
$210.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$306.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$229.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$210.53
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 81298-5010-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$306.23 |
| Rate for Payer: Cash Price |
$210.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$306.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$229.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$210.53
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 81298-5010-3
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$43.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$43.20
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 81298-5010-5
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 81298-5010-5
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$43.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$43.20
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$306.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$229.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$229.67
|
| Rate for Payer: Cash Price |
$210.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$306.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$229.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$229.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$210.53
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 81298-5010-3
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$306.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$229.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$229.67
|
| Rate for Payer: Cash Price |
$210.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$306.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$229.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$229.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$210.53
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
|
|
CARBOXYMETHYL 0.5 %-GLYCERIN 1 %-POLYSORB 80 0.5 %-PF EYE DROPPERETTE [201979]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 0023-4491-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
CARBOXYMETHYL 0.5 %-GLYCERIN 1 %-POLYSORB 80 0.5 %-PF EYE DROPPERETTE [201979]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 0023-4491-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 50268-068-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 0023-0798-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 69618-076-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 50268-068-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 0023-0798-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 69618-076-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0023-0403-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 0023-0403-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 0023-0403-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0023-0403-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE [38321]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0023-4554-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
