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
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.59
|
|
Service Code
|
NDC 68084-381-01
|
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 |
$0.32
|
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
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.17
|
|
Service Code
|
NDC 0603-2433-21
|
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
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.59
|
|
Service Code
|
NDC 68084-381-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.32 |
Max. Negotiated Rate |
$0.47 |
Rate for Payer: Cash Price |
$0.32
|
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
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.59
|
|
Service Code
|
NDC 68084-381-11
|
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 |
$0.32
|
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
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.17
|
|
Service Code
|
NDC 0603-2433-21
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.09 |
Max. Negotiated Rate |
$0.14 |
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: LLUH Dept of Risk Management WC |
$0.09
|
Rate for Payer: Multiplan Commercial |
$0.13
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.59
|
|
Service Code
|
NDC 68084-381-11
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.32 |
Max. Negotiated Rate |
$0.47 |
Rate for Payer: Cash Price |
$0.32
|
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
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]
|
Facility
|
OP
|
$36.00
|
|
Service Code
|
HCPCS J0515
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$19.80 |
Max. Negotiated Rate |
$28.80 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.60
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.92
|
Rate for Payer: Aetna of CA Government/Medicare |
$21.60
|
Rate for Payer: Aetna of CA Government/Medicare |
$16.92
|
Rate for Payer: Cash Price |
$19.80
|
Rate for Payer: Cash Price |
$15.51
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.56
|
Rate for Payer: Health Smart Auto/Commercial |
$16.92
|
Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.92
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.60
|
Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
Rate for Payer: LLUH Dept of Risk Management WC |
$15.51
|
Rate for Payer: Multiplan Commercial |
$27.00
|
Rate for Payer: Multiplan Commercial |
$21.15
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]
|
Facility
|
IP
|
$36.00
|
|
Service Code
|
HCPCS J0515
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$19.80 |
Max. Negotiated Rate |
$28.80 |
Rate for Payer: Cash Price |
$19.80
|
Rate for Payer: Cash Price |
$15.51
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.56
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
Rate for Payer: Health Smart Auto/Commercial |
$16.92
|
Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
Rate for Payer: LLUH Dept of Risk Management WC |
$15.51
|
Rate for Payer: Multiplan Commercial |
$21.15
|
Rate for Payer: Multiplan Commercial |
$27.00
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
OP
|
$0.19
|
|
Service Code
|
NDC 69315-137-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.15 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
Rate for Payer: Cash Price |
$0.11
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.14
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
OP
|
$0.19
|
|
Service Code
|
NDC 0603-2434-21
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.15 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
Rate for Payer: Cash Price |
$0.11
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.14
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
IP
|
$0.19
|
|
Service Code
|
NDC 0603-2434-21
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.15 |
Rate for Payer: Cash Price |
$0.11
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
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
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
IP
|
$0.19
|
|
Service Code
|
NDC 69315-137-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.15 |
Rate for Payer: Cash Price |
$0.11
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
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
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]
|
Facility
|
IP
|
$10.48
|
|
Service Code
|
HCPCS J0702
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$5.76 |
Max. Negotiated Rate |
$8.38 |
Rate for Payer: Cash Price |
$5.76
|
Rate for Payer: Cash Price |
$7.26
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.57
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.38
|
Rate for Payer: Health Smart Auto/Commercial |
$6.29
|
Rate for Payer: Health Smart Auto/Commercial |
$7.93
|
Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
Rate for Payer: LLUH Dept of Risk Management WC |
$7.27
|
Rate for Payer: Multiplan Commercial |
$9.91
|
Rate for Payer: Multiplan Commercial |
$7.86
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]
|
Facility
|
OP
|
$10.48
|
|
Service Code
|
HCPCS J0702
|
Hospital Charge Code |
901700025
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$5.76 |
Max. Negotiated Rate |
$8.38 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.29
|
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.93
|
Rate for Payer: Aetna of CA Government/Medicare |
$6.29
|
Rate for Payer: Aetna of CA Government/Medicare |
$7.93
|
Rate for Payer: Cash Price |
$5.76
|
Rate for Payer: Cash Price |
$7.26
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.38
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.57
|
Rate for Payer: Health Smart Auto/Commercial |
$6.29
|
Rate for Payer: Health Smart Auto/Commercial |
$7.93
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.29
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.93
|
Rate for Payer: LLUH Dept of Risk Management WC |
$7.27
|
Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
Rate for Payer: Multiplan Commercial |
$7.86
|
Rate for Payer: Multiplan Commercial |
$9.91
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]
|
Facility
|
OP
|
$2.84
|
|
Service Code
|
NDC 0472-0382-45
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.56 |
Max. Negotiated Rate |
$2.27 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.70
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.70
|
Rate for Payer: Cash Price |
$1.56
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.27
|
Rate for Payer: Health Smart Auto/Commercial |
$1.70
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.70
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
Rate for Payer: Multiplan Commercial |
$2.13
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]
|
Facility
|
IP
|
$2.84
|
|
Service Code
|
NDC 0472-0382-45
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.56 |
Max. Negotiated Rate |
$2.27 |
Rate for Payer: Cash Price |
$1.56
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.27
|
Rate for Payer: Health Smart Auto/Commercial |
$1.70
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
Rate for Payer: Multiplan Commercial |
$2.13
|
|
BETAMETHASONE DIPROPIONATE 0.05 % LOTION [1028]
|
Facility
|
OP
|
$0.80
|
|
Service Code
|
NDC 0168-0057-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.44 |
Max. Negotiated Rate |
$0.64 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.48
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.48
|
Rate for Payer: Cash Price |
$0.44
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.48
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
Rate for Payer: Multiplan Commercial |
$0.60
|
|
BETAMETHASONE DIPROPIONATE 0.05 % LOTION [1028]
|
Facility
|
IP
|
$0.80
|
|
Service Code
|
NDC 0168-0057-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.44 |
Max. Negotiated Rate |
$0.64 |
Rate for Payer: Cash Price |
$0.44
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
Rate for Payer: Multiplan Commercial |
$0.60
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM [1027]
|
Facility
|
OP
|
$2.59
|
|
Service Code
|
NDC 0472-0380-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.42 |
Max. Negotiated Rate |
$2.07 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.55
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.55
|
Rate for Payer: Cash Price |
$1.43
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.07
|
Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.55
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
Rate for Payer: Multiplan Commercial |
$1.94
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM [1027]
|
Facility
|
IP
|
$2.59
|
|
Service Code
|
NDC 0472-0380-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.42 |
Max. Negotiated Rate |
$2.07 |
Rate for Payer: Cash Price |
$1.43
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.07
|
Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
Rate for Payer: Multiplan Commercial |
$1.94
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
|
IP
|
$3.94
|
|
Service Code
|
NDC 0168-0056-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$2.17 |
Max. Negotiated Rate |
$3.15 |
Rate for Payer: Cash Price |
$2.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.15
|
Rate for Payer: Health Smart Auto/Commercial |
$2.36
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.17
|
Rate for Payer: Multiplan Commercial |
$2.96
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
|
OP
|
$3.14
|
|
Service Code
|
NDC 0472-0381-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.73 |
Max. Negotiated Rate |
$2.51 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.88
|
Rate for Payer: Aetna of CA Government/Medicare |
$1.88
|
Rate for Payer: Cash Price |
$1.73
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.51
|
Rate for Payer: Health Smart Auto/Commercial |
$1.88
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.88
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
Rate for Payer: Multiplan Commercial |
$2.35
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
|
IP
|
$3.14
|
|
Service Code
|
NDC 0472-0381-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$1.73 |
Max. Negotiated Rate |
$2.51 |
Rate for Payer: Cash Price |
$1.73
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.51
|
Rate for Payer: Health Smart Auto/Commercial |
$1.88
|
Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
Rate for Payer: Multiplan Commercial |
$2.35
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
|
OP
|
$3.94
|
|
Service Code
|
NDC 0168-0056-15
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$2.17 |
Max. Negotiated Rate |
$3.15 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.36
|
Rate for Payer: Aetna of CA Government/Medicare |
$2.36
|
Rate for Payer: Cash Price |
$2.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.15
|
Rate for Payer: Health Smart Auto/Commercial |
$2.36
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.36
|
Rate for Payer: LLUH Dept of Risk Management WC |
$2.17
|
Rate for Payer: Multiplan Commercial |
$2.96
|
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