|
BENZOYL PEROXIDE 2.5 % TOPICAL CLEANSER [9250]
|
Facility
IP
|
$1.09
|
|
|
Service Code
|
NDC 24470-911-08
|
| Hospital Charge Code |
NDG9250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-34
|
| Hospital Charge Code |
NDG993a
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-34
|
| Hospital Charge Code |
NDG993a
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-01
|
| Hospital Charge Code |
1743732
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER [993]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 45802-280-01
|
| Hospital Charge Code |
1743732
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 45802-216-96
|
| Hospital Charge Code |
NDG991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 45802-216-96
|
| Hospital Charge Code |
NDG991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1055-56
|
| Hospital Charge Code |
1743061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL GEL [991]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1055-56
|
| Hospital Charge Code |
1743061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2433-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-11
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2433-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
OP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-01
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-01
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2437-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
OP
|
$0.59
|
|
|
Service Code
|
NDC 60687-356-11
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
BENZTROPINE 0.5 MG TABLET [998]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 0603-2437-21
|
| Hospital Charge Code |
1711100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]
|
Facility
OP
|
$36.00
|
|
|
Service Code
|
CPT J0515
|
| Hospital Charge Code |
1720290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$40.38 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Adventist Health Commercial |
$6.60
|
| Rate for Payer: Adventist Health Commercial |
$5.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.05
|
| Rate for Payer: Blue Shield of California Commercial |
$24.97
|
| Rate for Payer: Blue Shield of California Commercial |
$24.97
|
| Rate for Payer: Blue Shield of California Commercial |
$24.97
|
| Rate for Payer: Blue Shield of California EPN |
$24.97
|
| Rate for Payer: Blue Shield of California EPN |
$24.97
|
| Rate for Payer: Blue Shield of California EPN |
$24.97
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.05
|
| Rate for Payer: Dignity Health Senior |
$28.05
|
| Rate for Payer: Dignity Health Senior |
$23.97
|
| Rate for Payer: Dignity Health Senior |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.06
|
| Rate for Payer: Heritage Provider Network Senior |
$13.06
|
| Rate for Payer: Heritage Provider Network Senior |
$16.67
|
| Rate for Payer: Heritage Provider Network Senior |
$15.28
|
| Rate for Payer: IEHP Medi-Cal |
$32.60
|
| Rate for Payer: IEHP Medi-Cal |
$32.60
|
| Rate for Payer: IEHP Medi-Cal |
$32.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$24.75
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$28.05
|
| Rate for Payer: Vantage Medical Group Senior |
$23.97
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]
|
Facility
IP
|
$33.00
|
|
|
Service Code
|
CPT J0515
|
| Hospital Charge Code |
1720290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.97 |
| Max. Negotiated Rate |
$24.75 |
| Rate for Payer: Adventist Health Commercial |
$6.60
|
| Rate for Payer: Adventist Health Commercial |
$5.64
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.37
|
| Rate for Payer: Heritage Provider Network Senior |
$22.34
|
| Rate for Payer: Heritage Provider Network Senior |
$19.09
|
| Rate for Payer: Heritage Provider Network Senior |
$24.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$24.75
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.03
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 69315-137-01
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 0603-2438-21
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 0603-2434-21
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 69315-137-01
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 0603-2438-21
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
BENZTROPINE 1 MG TABLET [999]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 0603-2434-21
|
| Hospital Charge Code |
1710776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
