|
HYDROCORTISONE 1 % TOPICAL OINTMENT [3731]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 24385-276-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.08
|
|
|
HYDROCORTISONE 1 % TOPICAL OINTMENT [3731]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 45802-276-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
HYDROCORTISONE 1 % TOPICAL OINTMENT [3731]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 24385-276-03
|
| Hospital Charge Code |
901700029
|
|
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| 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 Commercial |
$0.08
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 0115-1700-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.60
|
| 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: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 59762-0075-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
IP
|
$2.31
|
|
|
Service Code
|
NDC 50268-407-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$1.73
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 59762-0075-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 0115-1700-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| 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: Cash Price |
$0.60
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
OP
|
$2.31
|
|
|
Service Code
|
NDC 50268-407-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.39
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$1.73
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
OP
|
$2.31
|
|
|
Service Code
|
NDC 50268-407-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.39
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$1.73
|
|
|
HYDROCORTISONE 20 MG TABLET [3734]
|
Facility
|
IP
|
$2.31
|
|
|
Service Code
|
NDC 50268-407-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$1.73
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 51672-3003-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 51672-3003-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0472-0337-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0472-0337-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0168-0080-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.10
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 45802-004-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 45802-004-03
|
| 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 Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [3727]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0168-0080-31
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| 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 Commercial |
$0.10
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 62559-431-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 69315-312-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 64980-324-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 65649-401-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.91 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 65649-401-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.91 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 69315-312-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
