BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
OP
|
$0.36
|
|
Service Code
|
NDC 64380-712-06
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.20 |
Max. Negotiated Rate |
$0.29 |
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 |
$0.20
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
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 Commercial |
$0.27
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
IP
|
$0.56
|
|
Service Code
|
NDC 68084-214-11
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.31 |
Max. Negotiated Rate |
$0.45 |
Rate for Payer: Cash Price |
$0.31
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
Rate for Payer: Multiplan Commercial |
$0.42
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
IP
|
$0.36
|
|
Service Code
|
NDC 64380-712-06
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.20 |
Max. Negotiated Rate |
$0.29 |
Rate for Payer: Cash Price |
$0.20
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.27
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
IP
|
$0.56
|
|
Service Code
|
NDC 68084-214-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.31 |
Max. Negotiated Rate |
$0.45 |
Rate for Payer: Cash Price |
$0.31
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
Rate for Payer: Multiplan Commercial |
$0.42
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
OP
|
$0.59
|
|
Service Code
|
NDC 0904-7153-61
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.32 |
Max. Negotiated Rate |
$0.47 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
Rate for Payer: Cash Price |
$0.33
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
Rate for Payer: Multiplan Commercial |
$0.44
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
IP
|
$0.59
|
|
Service Code
|
NDC 0904-7153-61
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.32 |
Max. Negotiated Rate |
$0.47 |
Rate for Payer: Cash Price |
$0.33
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
Rate for Payer: Multiplan Commercial |
$0.44
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
OP
|
$0.17
|
|
Service Code
|
NDC 68382-247-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.09 |
Max. Negotiated Rate |
$0.14 |
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 |
$0.14
|
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 |
$0.13
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
IP
|
$0.18
|
|
Service Code
|
NDC 42806-714-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.14 |
Rate for Payer: Cash Price |
$0.10
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.14
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
IP
|
$0.36
|
|
Service Code
|
NDC 69452-143-20
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.20 |
Max. Negotiated Rate |
$0.29 |
Rate for Payer: Cash Price |
$0.20
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.27
|
|
BENZONATATE 100 MG CAPSULE [988]
|
Facility
|
OP
|
$0.56
|
|
Service Code
|
NDC 68084-214-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.31 |
Max. Negotiated Rate |
$0.45 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
Rate for Payer: Cash Price |
$0.31
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
Rate for Payer: Multiplan Commercial |
$0.42
|
|
BENZONATATE 200 MG CAPSULE [26953]
|
Facility
|
IP
|
$0.39
|
|
Service Code
|
NDC 51224-001-50
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.31 |
Rate for Payer: Cash Price |
$0.21
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.29
|
|
BENZONATATE 200 MG CAPSULE [26953]
|
Facility
|
OP
|
$0.39
|
|
Service Code
|
NDC 51224-001-50
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.31 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
Rate for Payer: Cash Price |
$0.21
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.29
|
|
BENZOYL PEROXIDE 10 % TOPICAL CLEANSER [996]
|
Facility
|
IP
|
$0.06
|
|
Service Code
|
NDC 67405-830-05
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.05
|
|
BENZOYL PEROXIDE 10 % TOPICAL CLEANSER [996]
|
Facility
|
OP
|
$0.06
|
|
Service Code
|
NDC 67405-830-05
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.05
|
|
BENZOYL PEROXIDE 10 % TOPICAL CLEANSER [996]
|
Facility
|
IP
|
$0.05
|
|
Service Code
|
NDC 0536-1351-42
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.04 |
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.04
|
|
BENZOYL PEROXIDE 10 % TOPICAL CLEANSER [996]
|
Facility
|
OP
|
$0.05
|
|
Service Code
|
NDC 0536-1351-42
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.04 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.04
|
|
BENZOYL PEROXIDE 10 % TOPICAL GEL [989]
|
Facility
|
OP
|
$0.28
|
|
Service Code
|
NDC 45802-308-96
|
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 |
$0.17
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
Rate for Payer: Multiplan Commercial |
$0.21
|
|
BENZOYL PEROXIDE 10 % TOPICAL GEL [989]
|
Facility
|
IP
|
$0.28
|
|
Service Code
|
NDC 45802-308-96
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.15 |
Max. Negotiated Rate |
$0.22 |
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
Rate for Payer: Multiplan Commercial |
$0.21
|
|
BENZOYL PEROXIDE 2.5 % TOPICAL CLEANSER [9250]
|
Facility
|
IP
|
$1.09
|
|
Service Code
|
NDC 24470-911-08
|
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
|
|
BENZOYL PEROXIDE 2.5 % TOPICAL CLEANSER [9250]
|
Facility
|
OP
|
$1.09
|
|
Service Code
|
NDC 24470-911-08
|
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
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
|
OP
|
$0.06
|
|
Service Code
|
NDC 45802-280-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.05
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
|
IP
|
$0.06
|
|
Service Code
|
NDC 45802-280-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.03 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Cash Price |
$0.03
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
Rate for Payer: Multiplan Commercial |
$0.05
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
IP
|
$0.28
|
|
Service Code
|
NDC 45802-216-96
|
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 |
$0.17
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
Rate for Payer: Multiplan Commercial |
$0.21
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
OP
|
$0.10
|
|
Service Code
|
NDC 0536-1055-56
|
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
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
OP
|
$0.28
|
|
Service Code
|
NDC 45802-216-96
|
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 |
$0.17
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
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 |
$0.17
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
Rate for Payer: Multiplan Commercial |
$0.21
|
|