|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 55150-249-50
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0409-1160-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 63323-465-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0409-1160-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION [153079]
|
Facility
|
OP
|
$23.92
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.35
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.16
|
| Rate for Payer: Multiplan Commercial |
$17.94
|
|
|
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION [153079]
|
Facility
|
IP
|
$23.92
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.16
|
| Rate for Payer: Multiplan Commercial |
$17.94
|
|
|
BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [231886]
|
Facility
|
IP
|
$26.90
|
|
|
Service Code
|
HCPCS C9088
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$21.52 |
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.79
|
| Rate for Payer: Multiplan Commercial |
$20.18
|
|
|
BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [231886]
|
Facility
|
OP
|
$26.90
|
|
|
Service Code
|
HCPCS C9088
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$21.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.14
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.79
|
| Rate for Payer: Multiplan Commercial |
$20.18
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 0409-3613-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 0409-3613-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 0409-3613-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 0409-3613-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]
|
Facility
|
IP
|
$95.32
|
|
|
Service Code
|
NDC 0093-3657-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$76.26 |
| Rate for Payer: Cash Price |
$52.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$76.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.43
|
| Rate for Payer: Multiplan Commercial |
$71.49
|
|
|
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]
|
Facility
|
OP
|
$95.32
|
|
|
Service Code
|
NDC 0093-3657-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$76.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.19
|
| Rate for Payer: Cash Price |
$52.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$76.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.43
|
| Rate for Payer: Multiplan Commercial |
$71.49
|
|
|
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]
|
Facility
|
OP
|
$95.32
|
|
|
Service Code
|
NDC 0093-3657-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$76.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.19
|
| Rate for Payer: Cash Price |
$52.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$76.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.43
|
| Rate for Payer: Multiplan Commercial |
$71.49
|
|
|
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]
|
Facility
|
IP
|
$95.32
|
|
|
Service Code
|
NDC 0093-3657-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$76.26 |
| Rate for Payer: Cash Price |
$52.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$76.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.43
|
| Rate for Payer: Multiplan Commercial |
$71.49
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM [106176]
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
|
