|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 60687-514-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.85
|
|
|
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
|
OP
|
$39.56
|
|
|
Service Code
|
CPT J0476
|
| Hospital Charge Code |
1757066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.76 |
| Max. Negotiated Rate |
$29.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$23.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$23.74
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$23.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$29.67
|
|
|
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
|
IP
|
$39.56
|
|
|
Service Code
|
CPT J0476
|
| Hospital Charge Code |
1757066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.76 |
| Max. Negotiated Rate |
$31.65 |
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$23.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.76
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$29.67
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
1715278
|
|
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
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
1715278
|
|
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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
1740393
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
1740393
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
1740041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.69
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0065-1795-04
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0065-1795-04
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
1740041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.69
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 59390-175-13
|
| Hospital Charge Code |
NDG118648
|
|
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: 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 Beech St/Commercial/PHCS |
$0.08
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 59390-175-13
|
| Hospital Charge Code |
NDG118648
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.08
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0378-6750-82
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.51
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 0054-0079-28
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 0378-6750-82
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.51 |
| 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 |
$0.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.51
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-13
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-11
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 0054-0079-28
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-13
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-11
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 58980-780-50
|
| Hospital Charge Code |
NDG203027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.12
|
|
|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 58980-780-50
|
| Hospital Charge Code |
NDG203027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.12
|
|
