|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 42195-955-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 51672-4222-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
BUTORPHANOL 10 MG/ML NASAL SPRAY [9335]
|
Facility
|
OP
|
$31.13
|
|
|
Service Code
|
NDC 60505-0813-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.12 |
| Max. Negotiated Rate |
$24.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.68
|
| Rate for Payer: Cash Price |
$17.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.12
|
| Rate for Payer: Multiplan Commercial |
$23.35
|
|
|
BUTORPHANOL 10 MG/ML NASAL SPRAY [9335]
|
Facility
|
IP
|
$31.13
|
|
|
Service Code
|
NDC 60505-0813-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.12 |
| Max. Negotiated Rate |
$24.90 |
| Rate for Payer: Cash Price |
$17.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.12
|
| Rate for Payer: Multiplan Commercial |
$23.35
|
|
|
BUTORPHANOL 1 MG/ML INJECTION SOLUTION [9333]
|
Facility
|
OP
|
$13.61
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.17
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.49
|
| Rate for Payer: Multiplan Commercial |
$10.21
|
|
|
BUTORPHANOL 1 MG/ML INJECTION SOLUTION [9333]
|
Facility
|
IP
|
$13.61
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.49
|
| Rate for Payer: Multiplan Commercial |
$10.21
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$8.79
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]
|
Facility
|
OP
|
$11.72
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.45 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.03
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.03
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.45
|
| Rate for Payer: Multiplan Commercial |
$8.79
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
BUTT PASTE OINT (LLUMC) [4080617]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 9994-0806-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$11.25
|
|
|
BUTT PASTE OINT (LLUMC) [4080617]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 9994-0806-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.00
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$11.25
|
|
|
CABERGOLINE 0.25 MG 1/2 TABLET [4081952]
|
Facility
|
OP
|
$5.59
|
|
|
Service Code
|
NDC 9994-0819-52
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.35
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.07
|
| Rate for Payer: Multiplan Commercial |
$4.19
|
|
|
CABERGOLINE 0.25 MG 1/2 TABLET [4081952]
|
Facility
|
IP
|
$5.59
|
|
|
Service Code
|
NDC 9994-0819-52
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.07
|
| Rate for Payer: Multiplan Commercial |
$4.19
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.46
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.25
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$2.81
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$7.50
|
|
|
Service Code
|
NDC 0093-5420-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.12
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$2.81
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$7.50
|
|
|
Service Code
|
NDC 0093-5420-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.12
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.04
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| 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 |
$0.10
|
| 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
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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 |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| 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 |
$0.12
|
|
