|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 76385-105-01
|
| Hospital Charge Code |
1710775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| 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 |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 |
$0.09
|
| 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 |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 76385-105-01
|
| Hospital Charge Code |
1710775
|
|
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 |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 0603-2439-21
|
| Hospital Charge Code |
1710775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 0603-2439-21
|
| Hospital Charge Code |
1710775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]
|
Facility
IP
|
$8.98
|
|
|
Service Code
|
CPT J0702
|
| Hospital Charge Code |
1720213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.74 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Adventist Health Commercial |
$2.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.17
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.08
|
| Rate for Payer: Heritage Provider Network Senior |
$6.08
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.91
|
| Rate for Payer: Multiplan Commercial |
$7.48
|
| Rate for Payer: Multiplan Commercial |
$6.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.33
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]
|
Facility
OP
|
$13.21
|
|
|
Service Code
|
CPT J0702
|
| Hospital Charge Code |
1720213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$2.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.42
|
| Rate for Payer: Blue Shield of California Commercial |
$8.01
|
| Rate for Payer: Blue Shield of California Commercial |
$8.01
|
| Rate for Payer: Blue Shield of California Commercial |
$8.01
|
| Rate for Payer: Blue Shield of California EPN |
$8.01
|
| Rate for Payer: Blue Shield of California EPN |
$8.01
|
| Rate for Payer: Blue Shield of California EPN |
$8.01
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.48
|
| Rate for Payer: Dignity Health Senior |
$8.48
|
| Rate for Payer: Dignity Health Senior |
$7.63
|
| Rate for Payer: Dignity Health Senior |
$11.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.62
|
| Rate for Payer: Heritage Provider Network Senior |
$4.16
|
| Rate for Payer: Heritage Provider Network Senior |
$4.62
|
| Rate for Payer: Heritage Provider Network Senior |
$6.12
|
| Rate for Payer: IEHP Medi-Cal |
$17.60
|
| Rate for Payer: IEHP Medi-Cal |
$17.60
|
| Rate for Payer: IEHP Medi-Cal |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$7.48
|
| Rate for Payer: Multiplan Commercial |
$6.74
|
| Rate for Payer: Multiplan Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.63
|
| Rate for Payer: Vantage Medical Group Senior |
$7.63
|
| Rate for Payer: Vantage Medical Group Senior |
$11.23
|
| Rate for Payer: Vantage Medical Group Senior |
$8.48
|
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM [9175]
|
Facility
OP
|
$0.56
|
|
|
Service Code
|
NDC 68462-290-17
|
| Hospital Charge Code |
1743496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM [9175]
|
Facility
IP
|
$0.56
|
|
|
Service Code
|
NDC 68462-290-17
|
| Hospital Charge Code |
1743496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]
|
Facility
OP
|
$2.84
|
|
|
Service Code
|
NDC 0472-0382-45
|
| Hospital Charge Code |
1743379
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.41
|
| Rate for Payer: Dignity Health Senior |
$2.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.41
|
| Rate for Payer: Vantage Medical Group Senior |
$2.41
|
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]
|
Facility
IP
|
$2.84
|
|
|
Service Code
|
NDC 0472-0382-45
|
| Hospital Charge Code |
1743379
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % LOTION [1028]
|
Facility
IP
|
$0.80
|
|
|
Service Code
|
NDC 0168-0057-60
|
| Hospital Charge Code |
1743383
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % LOTION [1028]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
NDC 0168-0057-60
|
| Hospital Charge Code |
1743383
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM [1027]
|
Facility
IP
|
$2.59
|
|
|
Service Code
|
NDC 0472-0380-15
|
| Hospital Charge Code |
1743546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.78
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM [1027]
|
Facility
OP
|
$2.59
|
|
|
Service Code
|
NDC 0472-0380-15
|
| Hospital Charge Code |
1743546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.20
|
| Rate for Payer: Dignity Health Senior |
$2.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2.20
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
OP
|
$3.14
|
|
|
Service Code
|
NDC 0472-0381-15
|
| Hospital Charge Code |
1743377
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: Dignity Health Senior |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.67
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 0168-0056-15
|
| Hospital Charge Code |
1743377
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.31
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Senior |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
IP
|
$3.14
|
|
|
Service Code
|
NDC 0472-0381-15
|
| Hospital Charge Code |
1743377
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Senior |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 0168-0056-15
|
| Hospital Charge Code |
1743377
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM [1031]
|
Facility
IP
|
$1.43
|
|
|
Service Code
|
NDC 51672-1269-1
|
| Hospital Charge Code |
1743469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM [1031]
|
Facility
IP
|
$1.43
|
|
|
Service Code
|
NDC 0713-0326-15
|
| Hospital Charge Code |
1743469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM [1031]
|
Facility
OP
|
$1.43
|
|
|
Service Code
|
NDC 0713-0326-15
|
| Hospital Charge Code |
1743469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM [1031]
|
Facility
OP
|
$1.43
|
|
|
Service Code
|
NDC 51672-1269-1
|
| Hospital Charge Code |
1743469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL OINTMENT [1033]
|
Facility
OP
|
$0.89
|
|
|
Service Code
|
NDC 0168-0033-46
|
| Hospital Charge Code |
1743276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.76
|
| Rate for Payer: Dignity Health Senior |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Vantage Medical Group Senior |
$0.76
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL OINTMENT [1033]
|
Facility
OP
|
$1.30
|
|
|
Service Code
|
NDC 0472-0371-15
|
| Hospital Charge Code |
NDG1033
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL OINTMENT [1033]
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
NDC 0168-0033-15
|
| Hospital Charge Code |
NDG1033
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
