|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.85
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.85
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.66 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.66
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.66 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.27
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.66
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.66 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.66
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.66 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19.27
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$25.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.66
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 43547-336-10
|
| 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
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 43547-336-10
|
| 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
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65162-752-10
|
| 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
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65162-752-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| 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: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-116-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| 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: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-116-01
|
| 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
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-117-01
|
| 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
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 65162-753-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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 |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 50268-111-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 43547-337-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 43547-337-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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 |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-117-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| 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: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 50268-111-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.69 |
| 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 |
$0.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
| 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 |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
