|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
IP
|
$7.07
|
|
|
Service Code
|
NDC 0781-7117-35
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$5.66 |
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.30
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
OP
|
$7.07
|
|
|
Service Code
|
NDC 0781-7117-35
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$5.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.24
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.30
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 68462-501-65
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.65
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.31
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 68462-501-65
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.31
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 66993-878-61
|
| Hospital Charge Code |
NDG12244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Health Smart Auto/Commercial |
$3.62
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.52
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 66993-878-61
|
| Hospital Charge Code |
NDG12244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.62
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.52
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
|
IP
|
$19.82
|
|
|
Service Code
|
NDC 50222-227-81
|
| Hospital Charge Code |
NDG70383
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.90 |
| Max. Negotiated Rate |
$15.86 |
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.86
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
|
IP
|
$23.78
|
|
|
Service Code
|
NDC 50222-227-04
|
| Hospital Charge Code |
1743778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$19.02 |
| Rate for Payer: Cash Price |
$10.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$17.84
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
|
OP
|
$19.82
|
|
|
Service Code
|
NDC 50222-227-81
|
| Hospital Charge Code |
NDG70383
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.90 |
| Max. Negotiated Rate |
$14.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.89
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.86
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
|
OP
|
$23.78
|
|
|
Service Code
|
NDC 50222-227-04
|
| Hospital Charge Code |
1743778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$17.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.27
|
| Rate for Payer: Cash Price |
$10.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$17.84
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]
|
Facility
|
OP
|
$25.28
|
|
|
Service Code
|
NDC 50222-501-06
|
| Hospital Charge Code |
NDG91914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$18.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.17
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.96
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]
|
Facility
|
IP
|
$25.28
|
|
|
Service Code
|
NDC 50222-501-06
|
| Hospital Charge Code |
NDG91914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$20.22 |
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.96
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]
|
Facility
|
OP
|
$24.28
|
|
|
Service Code
|
NDC 60505-0823-6
|
| Hospital Charge Code |
1744077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.21
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]
|
Facility
|
IP
|
$24.28
|
|
|
Service Code
|
NDC 60505-0823-6
|
| Hospital Charge Code |
1744077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$19.42 |
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.21
|
|
|
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]
|
Facility
|
IP
|
$1,878.60
|
|
|
Service Code
|
CPT J0630
|
| Hospital Charge Code |
1720101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,033.23 |
| Max. Negotiated Rate |
$1,502.88 |
| Rate for Payer: Cash Price |
$845.37
|
| Rate for Payer: Cash Price |
$845.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,503.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,502.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,127.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,127.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,033.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,033.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,409.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,408.95
|
|
|
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]
|
Facility
|
OP
|
$1,879.26
|
|
|
Service Code
|
CPT J0630
|
| Hospital Charge Code |
1720101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,033.59 |
| Max. Negotiated Rate |
$1,409.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,127.56
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,127.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,127.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,127.16
|
| Rate for Payer: Cash Price |
$845.37
|
| Rate for Payer: Cash Price |
$845.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,127.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,127.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,127.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,127.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,033.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,033.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,409.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,408.95
|
|
|
CALCITRIOL 0.25 MCG CAPSULE [9350]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 64380-723-06
|
| Hospital Charge Code |
1710534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
|
CALCITRIOL 0.25 MCG CAPSULE [9350]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 0054-0007-25
|
| Hospital Charge Code |
1710534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.86
|
|
|
CALCITRIOL 0.25 MCG CAPSULE [9350]
|
Facility
|
IP
|
$0.89
|
|
|
Service Code
|
NDC 60687-345-11
|
| Hospital Charge Code |
1710534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.67
|
|
|
CALCITRIOL 0.25 MCG CAPSULE [9350]
|
Facility
|
OP
|
$0.89
|
|
|
Service Code
|
NDC 60687-345-01
|
| Hospital Charge Code |
1710534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.53
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.67
|
|
|
CALCITRIOL 0.25 MCG CAPSULE [9350]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 64380-723-06
|
| Hospital Charge Code |
1710534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| 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: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
|
CALCITRIOL 0.25 MCG CAPSULE [9350]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 69452-207-13
|
| Hospital Charge Code |
1710534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| 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: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
