BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$0.09
|
|
Service Code
|
NDC 0713-0280-31
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$0.15
|
|
Service Code
|
NDC 45802-060-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.08 |
Max. Negotiated Rate |
$0.12 |
Rate for Payer: Cash Price |
$0.08
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
Rate for Payer: Multiplan Commercial |
$0.11
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$0.09
|
|
Service Code
|
NDC 68001-477-47
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$0.08
|
|
Service Code
|
NDC 0536-1256-28
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.04 |
Max. Negotiated Rate |
$0.06 |
Rate for Payer: Cash Price |
$0.04
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
Rate for Payer: Multiplan Commercial |
$0.06
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$0.10
|
|
Service Code
|
NDC 45802-060-03
|
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 |
$0.06
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
IP
|
$0.16
|
|
Service Code
|
NDC 45802-060-00
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
IP
|
$0.16
|
|
Service Code
|
NDC 45802-060-70
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
IP
|
$0.16
|
|
Service Code
|
NDC 68001-477-48
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
OP
|
$0.16
|
|
Service Code
|
NDC 45802-060-70
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
OP
|
$0.16
|
|
Service Code
|
NDC 68001-477-45
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
OP
|
$0.16
|
|
Service Code
|
NDC 68001-477-48
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
OP
|
$0.16
|
|
Service Code
|
NDC 45802-060-00
|
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
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
IP
|
$0.16
|
|
Service Code
|
NDC 68001-477-45
|
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
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
|
IP
|
$7.86
|
|
Service Code
|
NDC 24208-555-55
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$4.32 |
Max. Negotiated Rate |
$6.29 |
Rate for Payer: Cash Price |
$4.32
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.29
|
Rate for Payer: Health Smart Auto/Commercial |
$4.72
|
Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
Rate for Payer: Multiplan Commercial |
$5.89
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
|
OP
|
$7.86
|
|
Service Code
|
NDC 24208-555-55
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$4.32 |
Max. Negotiated Rate |
$6.29 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.72
|
Rate for Payer: Aetna of CA Government/Medicare |
$4.72
|
Rate for Payer: Cash Price |
$4.32
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.29
|
Rate for Payer: Health Smart Auto/Commercial |
$4.72
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.72
|
Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
Rate for Payer: Multiplan Commercial |
$5.89
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]
|
Facility
|
OP
|
$0.27
|
|
Service Code
|
NDC 51672-2075-1
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.15 |
Max. Negotiated Rate |
$0.22 |
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 |
$0.15
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
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 |
$0.15
|
Rate for Payer: Multiplan Commercial |
$0.20
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]
|
Facility
|
IP
|
$0.27
|
|
Service Code
|
NDC 51672-2075-1
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.15 |
Max. Negotiated Rate |
$0.22 |
Rate for Payer: Cash Price |
$0.15
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
Rate for Payer: Multiplan Commercial |
$0.20
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
OP
|
$0.31
|
|
Service Code
|
NDC 69968-060-03
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.25 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
Rate for Payer: Cash Price |
$0.17
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
IP
|
$0.30
|
|
Service Code
|
NDC 58980-012-05
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.24 |
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
OP
|
$0.23
|
|
Service Code
|
NDC 51672-2044-2
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.13 |
Max. Negotiated Rate |
$0.18 |
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: Cash Price |
$0.13
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
Rate for Payer: Multiplan Commercial |
$0.17
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
IP
|
$0.42
|
|
Service Code
|
NDC 0081079888
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.23 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Cash Price |
$0.23
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
Rate for Payer: Multiplan Commercial |
$0.32
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
IP
|
$0.31
|
|
Service Code
|
NDC 69968-060-03
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.25 |
Rate for Payer: Cash Price |
$0.17
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
OP
|
$0.42
|
|
Service Code
|
NDC 0081079888
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.23 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
Rate for Payer: Cash Price |
$0.23
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
Rate for Payer: Multiplan Commercial |
$0.32
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
OP
|
$0.30
|
|
Service Code
|
NDC 58980-012-05
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.24 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
IP
|
$0.23
|
|
Service Code
|
NDC 51672-2044-2
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.13 |
Max. Negotiated Rate |
$0.18 |
Rate for Payer: Cash Price |
$0.13
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
Rate for Payer: Multiplan Commercial |
$0.17
|
|