|
BENZOYL PEROXIDE 10 % TOPICAL GEL [989]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 45802-308-96
|
| Hospital Charge Code |
1743042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| 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 |
$0.13
|
| 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 Beech St/Commercial/PHCS |
$0.21
|
|
|
BENZOYL PEROXIDE 10 % TOPICAL GEL [989]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 45802-308-96
|
| Hospital Charge Code |
1743042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.21
|
|
|
BENZOYL PEROXIDE 2.5 % TOPICAL CLEANSER [9250]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 24470-911-08
|
| Hospital Charge Code |
NDG9250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.82
|
|
|
BENZOYL PEROXIDE 2.5 % TOPICAL CLEANSER [9250]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 24470-911-08
|
| Hospital Charge Code |
NDG9250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.82 |
| 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 |
$0.49
|
| 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 Beech St/Commercial/PHCS |
$0.82
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-34
|
| Hospital Charge Code |
NDG993a
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-01
|
| Hospital Charge Code |
1743732
|
|
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: 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 Beech St/Commercial/PHCS |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-01
|
| Hospital Charge Code |
1743732
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-34
|
| Hospital Charge Code |
NDG993a
|
|
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: 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 Beech St/Commercial/PHCS |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 45802-216-96
|
| Hospital Charge Code |
NDG991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| 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 |
$0.13
|
| 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 Beech St/Commercial/PHCS |
$0.21
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 45802-216-96
|
| Hospital Charge Code |
NDG991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.21
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1055-56
|
| Hospital Charge Code |
1743061
|
|
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
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1055-56
|
| Hospital Charge Code |
1743061
|
|
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
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-11
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-11
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2433-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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 |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-01
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2437-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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 |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-01
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2433-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| 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 |
$0.08
|
| 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 Beech St/Commercial/PHCS |
$0.13
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2437-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| 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 |
$0.08
|
| 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 Beech St/Commercial/PHCS |
$0.13
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
CPT J0515
|
| Hospital Charge Code |
1720290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19.80
|
| 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 |
$19.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.92
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.80
|
| 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 |
$19.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$27.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$24.75
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
CPT J0515
|
| Hospital Charge Code |
1720290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.15 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.15
|
| 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 Beech St/Commercial/PHCS |
$24.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$27.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.15
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 69315-137-01
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| 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 |
$0.09
|
| 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 0603-2438-21
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| 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 |
$0.09
|
| 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 0603-2438-21
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.14
|
|
