|
NADOLOL 40 MG TABLET [5331]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 69097-868-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
NADOLOL 40 MG TABLET [5331]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 69097-868-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
NADOLOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080308]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0803-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
NADOLOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080308]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0803-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION [5334]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J2290
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$101.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$80.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$101.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$80.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$72.00
|
| Rate for Payer: Cash Price |
$93.42
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$73.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$107.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$135.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$80.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$80.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$101.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.42
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$100.35
|
| Rate for Payer: Multiplan Commercial |
$127.39
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION [5334]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J2290
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$93.42
|
| Rate for Payer: Cash Price |
$73.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$107.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$135.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$80.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.59
|
| Rate for Payer: Multiplan Commercial |
$100.35
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$127.39
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION [5333]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
HCPCS J2290
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Cash Price |
$9.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.27
|
| Rate for Payer: Multiplan Commercial |
$13.40
|
| Rate for Payer: Multiplan Commercial |
$10.35
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Multiplan Commercial |
$10.53
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION [5333]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
HCPCS J2290
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.84
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.72
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.42
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cash Price |
$9.83
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.72
|
| Rate for Payer: Multiplan Commercial |
$13.40
|
| Rate for Payer: Multiplan Commercial |
$10.53
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Multiplan Commercial |
$10.35
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
NAFCILLIN 2 GRAM SOLUTION FOR INJECTION [5335]
|
Facility
|
IP
|
$11.10
|
|
|
Service Code
|
HCPCS J2290
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Cash Price |
$6.11
|
| Rate for Payer: Cash Price |
$14.52
|
| Rate for Payer: Cash Price |
$19.07
|
| Rate for Payer: Cash Price |
$14.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$27.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.32
|
| Rate for Payer: Multiplan Commercial |
$26.00
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
|
|
NAFCILLIN 2 GRAM SOLUTION FOR INJECTION [5335]
|
Facility
|
OP
|
$26.04
|
|
|
Service Code
|
HCPCS J2290
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$20.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.66
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.84
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$20.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$20.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.84
|
| Rate for Payer: Cash Price |
$6.11
|
| Rate for Payer: Cash Price |
$14.52
|
| Rate for Payer: Cash Price |
$14.32
|
| Rate for Payer: Cash Price |
$19.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$27.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.07
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: Multiplan Commercial |
$26.00
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
IP
|
$5.35
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.53
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
OP
|
$4.71
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.83
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.83
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
| Rate for Payer: Multiplan Commercial |
$3.53
|
|
|
NALBUPHINE 20 MG/ML INJECTION SOLUTION [5340]
|
Facility
|
IP
|
$9.20
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.06
|
| Rate for Payer: Multiplan Commercial |
$6.90
|
|
|
NALBUPHINE 20 MG/ML INJECTION SOLUTION [5340]
|
Facility
|
OP
|
$9.20
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.52
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.06
|
| Rate for Payer: Multiplan Commercial |
$6.90
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
OP
|
$17.46
|
|
|
Service Code
|
NDC 82625-8802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.48
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$13.10
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
IP
|
$17.46
|
|
|
Service Code
|
NDC 82625-8802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$13.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$13.10
|
|
|
NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.20
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
NALOXONE 1 MG/ML 2 ML SYRINGE - CODE [4080581]
|
Facility
|
OP
|
$19.80
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$15.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.88
|
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.89
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
|
|
NALOXONE 1 MG/ML 2 ML SYRINGE - CODE [4080581]
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$15.84 |
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.89
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
|
|
NALOXONE 1 MG/ML INJECTION SYRINGE [5374]
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$15.84 |
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.89
|
| Rate for Payer: Multiplan Commercial |
$14.11
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
|
|
NALOXONE 1 MG/ML INJECTION SYRINGE [5374]
|
Facility
|
OP
|
$18.81
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.35 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.29
|
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.89
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
| Rate for Payer: Multiplan Commercial |
$14.11
|
|
|
NALOXONE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080435]
|
Facility
|
OP
|
$10.45
|
|
|
Service Code
|
NDC 9994-0804-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.27
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
|
|
NALOXONE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080435]
|
Facility
|
IP
|
$10.45
|
|
|
Service Code
|
NDC 9994-0804-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 0406-1170-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
