|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
IP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-11
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
OP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-20
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE [208776]
|
Facility
|
IP
|
$6.27
|
|
|
Service Code
|
NDC 64896-664-01
|
| Hospital Charge Code |
ERX208776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$5.02 |
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.70
|
|
|
CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE [208776]
|
Facility
|
OP
|
$6.27
|
|
|
Service Code
|
NDC 64896-664-01
|
| Hospital Charge Code |
ERX208776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.76
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.70
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.63
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.89
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.89
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| 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 Beech St/Commercial/PHCS |
$0.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.50
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
NDG39265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.64
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
NDG39265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.31
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.64
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.63
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.68
|
| 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 Beech St/Commercial/PHCS |
$1.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.86
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$287.09 |
| 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 |
$172.26
|
| 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 Beech St/Commercial/PHCS |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-5
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$142.08 |
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$142.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-3
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$142.08 |
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$142.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-1
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$142.08 |
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$142.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-3
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$106.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$106.56
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$106.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$306.23 |
| Rate for Payer: Cash Price |
$172.26
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-5
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$106.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$106.56
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$106.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
IP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$306.23 |
| Rate for Payer: Cash Price |
$172.26
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-1
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$106.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$106.56
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$106.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
|
OP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.53 |
| Max. Negotiated Rate |
$287.09 |
| 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 |
$172.26
|
| 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 Beech St/Commercial/PHCS |
$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 |
ERX201979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$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 |
ERX201979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.36 |
| 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 |
$0.22
|
| 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 Beech St/Commercial/PHCS |
$0.36
|
|
