|
ACYCLOVIR 200 MG CAPSULE [8969]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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 |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
ACYCLOVIR 200 MG CAPSULE [8969]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| 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: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| 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 |
$0.31
|
| 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: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.09
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| 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: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 7257808201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$3.27
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 7257808201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.49 |
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$3.27
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 6516283594
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 6516283594
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.90
|
|
|
ACYCLOVIR 800 MG TABLET [8972]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.11
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| 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 Commercial |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
ACYCLOVIR 800 MG TABLET [8972]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.87
|
| 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: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| 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 Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$4.05
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$4.32 |
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| 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 |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.03
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| 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: Aetna of CA Government/Medicare |
$1.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| 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 |
$1.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
IP
|
$153.63
|
|
|
Service Code
|
NDC 8073981218
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$122.90 |
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$122.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$92.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.50
|
| Rate for Payer: Multiplan Commercial |
$115.22
|
|
|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
OP
|
$153.63
|
|
|
Service Code
|
NDC 8073981218
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$122.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$92.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$92.18
|
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$122.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$92.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$92.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.50
|
| Rate for Payer: Multiplan Commercial |
$115.22
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 4580245384
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 4580245384
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.62
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.61
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$5.26 |
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.61
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$5.26 |
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.61
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$5.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.94
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.61
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.43
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.30
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.29
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$3.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$2.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$4.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$4.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
|
|
ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 5816082903
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
