|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
|
OP
|
$4.04
|
|
|
Service Code
|
NDC 60687-583-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.42
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
|
IP
|
$4.04
|
|
|
Service Code
|
NDC 60687-583-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 51672-4124-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| 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 |
$0.59
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 54092-173-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
|
OP
|
$1.96
|
|
|
Service Code
|
NDC 66993-409-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.18
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 54092-173-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
|
IP
|
$1.96
|
|
|
Service Code
|
NDC 66993-409-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
|
|
CARBAMAZEPINE ER 400 MG TABLET,EXTENDED RELEASE,12 HR [27636]
|
Facility
|
IP
|
$7.91
|
|
|
Service Code
|
NDC 0078-0512-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$6.33 |
| Rate for Payer: Cash Price |
$4.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.35
|
| Rate for Payer: Multiplan Commercial |
$5.93
|
|
|
CARBAMAZEPINE ER 400 MG TABLET,EXTENDED RELEASE,12 HR [27636]
|
Facility
|
OP
|
$7.91
|
|
|
Service Code
|
NDC 0078-0512-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$6.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.75
|
| Rate for Payer: Cash Price |
$4.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.35
|
| Rate for Payer: Multiplan Commercial |
$5.93
|
|
|
CARBAMIDE PEROXIDE 10 % ORAL RINSE [1358]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 63029-500-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
CARBAMIDE PEROXIDE 10 % ORAL RINSE [1358]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 63029-500-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| 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 |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| 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 |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 4203710478
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 8770143152
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| 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: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 0904-6627-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 8770143151
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| 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
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 46122-556-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| 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 |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 8770143151
|
| 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 |
$0.12
|
| 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 Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 8770143152
|
| 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
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0074-7362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| 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 |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| 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 |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 4203710478
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 46122-557-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| 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 |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 0904-6627-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0074-7362-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 46122-556-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| 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 |
$0.18
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 46122-557-05
|
| 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 |
$0.10
|
| 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 Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
