|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 45802-060-00
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.12
|
|
|
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 |
1740295
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$5.90 |
| 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 |
$3.54
|
| 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 Beech St/Commercial/PHCS |
$5.90
|
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
|
OP
|
$4.77
|
|
|
Service Code
|
NDC 17478-238-35
|
| Hospital Charge Code |
1740295
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.58
|
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
|
IP
|
$4.77
|
|
|
Service Code
|
NDC 17478-238-35
|
| Hospital Charge Code |
1740295
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.58
|
|
|
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 |
1740295
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$6.29 |
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$5.90
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 51672-2075-1
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.20
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 51672-2075-1
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.20 |
| 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 |
$0.12
|
| 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 Beech St/Commercial/PHCS |
$0.20
|
|
|
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 |
NDG116219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.10
|
| 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 Beech St/Commercial/PHCS |
$0.17
|
|
|
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 |
NDG116219A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.23
|
|
|
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 |
NDG116219A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| 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 |
$0.14
|
| 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 Beech St/Commercial/PHCS |
$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 |
NDG116219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.17
|
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 81079888
|
| Hospital Charge Code |
1743444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.27
|
|
|
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 |
NDG116219A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.23
|
|
|
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 |
NDG116219A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| 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 |
$0.14
|
| 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 Beech St/Commercial/PHCS |
$0.23
|
|
|
BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT [116219]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 81079888
|
| Hospital Charge Code |
1743444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.27 |
| 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 |
$0.16
|
| 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 Beech St/Commercial/PHCS |
$0.27
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 68084-855-01
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0527-1330-01
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0527-1330-01
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| 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 |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 29300-343-01
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 68084-855-11
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 50268-106-15
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| 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 |
$0.28
|
| 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 Beech St/Commercial/PHCS |
$0.47
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 70710-1285-1
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 50268-106-11
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.47
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 50268-106-11
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| 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 |
$0.28
|
| 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 Beech St/Commercial/PHCS |
$0.47
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 68084-855-11
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
