|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.51
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.51
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
|
|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
|
|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 9999902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0904648838
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 0904648838
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.11
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [119919]
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
NDC 0065051801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.47
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [119919]
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 0065051801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT [115913]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 4628750704
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| 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
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT [115913]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 4628750704
|
| 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 |
$0.05
|
| 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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
HCPCS S0104
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.08
|
| 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: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
HCPCS S0104
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| 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
|
|
|
ZINC 50 MG (AS GLUCONATE) TABLET [8872]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 7431202060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
ZINC 50 MG (AS GLUCONATE) TABLET [8872]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 7431202060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 7733398310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 7733398310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.17
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 2055504000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 7733398325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.17
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 2055504000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068113500
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 7733398325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068113500
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) TABLET [8881]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 1000673027
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| 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
|
|
|
ZINC 50 MG (AS ZINC SULFATE 220 MG) TABLET [8881]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 1000673027
|
| 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 |
$0.02
|
| 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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION [8865]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Cash Price |
$1.28
|
| 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
|
|
|
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION [8865]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 |
$1.28
|
| 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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
|
