|
NIMODIPINE ORAL SUSPENSION COMPOUND 30 MG/ML [4080312]
|
Facility
|
OP
|
$9.15
|
|
|
Service Code
|
NDC 9994-0803-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$7.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.49
|
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.03
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
|
|
NIMODIPINE ORAL SUSPENSION COMPOUND 30 MG/ML [4080312]
|
Facility
|
IP
|
$9.15
|
|
|
Service Code
|
NDC 9994-0803-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$7.32 |
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.03
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
|
|
NIRMATRELVIR 150 MG (10)-RITONAVIR 100 MG (10) TABLETS IN A DOSE PACK [234239]
|
Facility
|
OP
|
$89.77
|
|
|
Service Code
|
NDC 0069-5317-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$71.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$53.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$53.86
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$71.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$53.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$53.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.37
|
| Rate for Payer: Multiplan Commercial |
$67.33
|
|
|
NIRMATRELVIR 150 MG (10)-RITONAVIR 100 MG (10) TABLETS IN A DOSE PACK [234239]
|
Facility
|
IP
|
$89.77
|
|
|
Service Code
|
NDC 0069-5317-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$71.82 |
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$71.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$53.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.37
|
| Rate for Payer: Multiplan Commercial |
$67.33
|
|
|
NIRMATRELVIR 150 MG (10)-RITONAVIR 100 MG (10) TABLETS IN A DOSE PACK [234239]
|
Facility
|
OP
|
$89.77
|
|
|
Service Code
|
NDC 0069-5317-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$71.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$53.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$53.86
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$71.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$53.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$53.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.37
|
| Rate for Payer: Multiplan Commercial |
$67.33
|
|
|
NIRMATRELVIR 150 MG (10)-RITONAVIR 100 MG (10) TABLETS IN A DOSE PACK [234239]
|
Facility
|
IP
|
$89.77
|
|
|
Service Code
|
NDC 0069-5317-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$71.82 |
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$71.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$53.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.37
|
| Rate for Payer: Multiplan Commercial |
$67.33
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
|
IP
|
$59.84
|
|
|
Service Code
|
NDC 0069-5321-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.91 |
| Max. Negotiated Rate |
$47.87 |
| Rate for Payer: Cash Price |
$32.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.91
|
| Rate for Payer: Multiplan Commercial |
$44.88
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
|
OP
|
$59.84
|
|
|
Service Code
|
NDC 0069-5321-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.91 |
| Max. Negotiated Rate |
$47.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$35.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$35.90
|
| Rate for Payer: Cash Price |
$32.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$35.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.91
|
| Rate for Payer: Multiplan Commercial |
$44.88
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
|
IP
|
$59.84
|
|
|
Service Code
|
NDC 0069-5321-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.91 |
| Max. Negotiated Rate |
$47.87 |
| Rate for Payer: Cash Price |
$32.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.91
|
| Rate for Payer: Multiplan Commercial |
$44.88
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
|
OP
|
$59.84
|
|
|
Service Code
|
NDC 0069-5321-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.91 |
| Max. Negotiated Rate |
$47.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$35.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$35.90
|
| Rate for Payer: Cash Price |
$32.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$35.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.91
|
| Rate for Payer: Multiplan Commercial |
$44.88
|
|
|
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE [239073]
|
Facility
|
IP
|
$667.36
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.05 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Cash Price |
$367.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$533.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$400.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$367.05
|
| Rate for Payer: Multiplan Commercial |
$500.52
|
|
|
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE [239073]
|
Facility
|
OP
|
$667.36
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.05 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$400.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$400.42
|
| Rate for Payer: Cash Price |
$367.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$533.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$400.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$400.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$367.05
|
| Rate for Payer: Multiplan Commercial |
$500.52
|
|
|
NITAZOXANIDE 100 MG/5 ML ORAL SUSPENSION [34708]
|
Facility
|
OP
|
$10.44
|
|
|
Service Code
|
NDC 67546-212-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$8.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.26
|
| Rate for Payer: Cash Price |
$5.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$7.83
|
|
|
NITAZOXANIDE 100 MG/5 ML ORAL SUSPENSION [34708]
|
Facility
|
IP
|
$10.44
|
|
|
Service Code
|
NDC 67546-212-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$8.35 |
| Rate for Payer: Cash Price |
$5.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$7.83
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
IP
|
$156.11
|
|
|
Service Code
|
NDC 64980-526-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$85.86 |
| Max. Negotiated Rate |
$124.89 |
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$124.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$93.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.86
|
| Rate for Payer: Multiplan Commercial |
$117.08
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
IP
|
$70.25
|
|
|
Service Code
|
NDC 64980-526-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$56.20 |
| Rate for Payer: Cash Price |
$38.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$56.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$42.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
IP
|
$161.56
|
|
|
Service Code
|
NDC 67546-111-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.86 |
| Max. Negotiated Rate |
$129.25 |
| Rate for Payer: Cash Price |
$88.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$129.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$96.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.86
|
| Rate for Payer: Multiplan Commercial |
$121.17
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
OP
|
$173.90
|
|
|
Service Code
|
NDC 67546-111-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$95.64 |
| Max. Negotiated Rate |
$139.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$104.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$104.34
|
| Rate for Payer: Cash Price |
$95.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$139.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$104.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$104.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.64
|
| Rate for Payer: Multiplan Commercial |
$130.43
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
OP
|
$70.25
|
|
|
Service Code
|
NDC 64980-526-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$56.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$42.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$42.15
|
| Rate for Payer: Cash Price |
$38.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$56.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$42.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$42.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 67546-111-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$95.64 |
| Max. Negotiated Rate |
$139.12 |
| Rate for Payer: Cash Price |
$95.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$139.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$104.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.64
|
| Rate for Payer: Multiplan Commercial |
$130.43
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
OP
|
$156.11
|
|
|
Service Code
|
NDC 64980-526-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$85.86 |
| Max. Negotiated Rate |
$124.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$93.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$93.67
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$124.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$93.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$93.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.86
|
| Rate for Payer: Multiplan Commercial |
$117.08
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
|
OP
|
$161.56
|
|
|
Service Code
|
NDC 67546-111-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.86 |
| Max. Negotiated Rate |
$129.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$96.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$96.94
|
| Rate for Payer: Cash Price |
$88.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$129.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$96.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$96.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.86
|
| Rate for Payer: Multiplan Commercial |
$121.17
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 50268-624-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$2.59
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
|
OP
|
$1.99
|
|
|
Service Code
|
NDC 68001-605-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
|
IP
|
$1.99
|
|
|
Service Code
|
NDC 68001-605-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
|
