|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION [5334]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
1751326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$80.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$101.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$80.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$101.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$72.00
|
| Rate for Payer: Cash Price |
$76.44
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$60.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$80.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| 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 |
$93.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$100.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$90.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$127.40
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION [5334]
|
Facility
|
IP
|
$133.80
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
1751326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.59 |
| Max. Negotiated Rate |
$107.04 |
| Rate for Payer: Cash Price |
$60.21
|
| Rate for Payer: Cash Price |
$76.44
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$107.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$135.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$80.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$127.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$90.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$100.35
|
|
|
NAFCILLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [10681]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
NDG10681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
|
|
NAFCILLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [10681]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
NDG10681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION [5333]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
1720545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$6.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.72
|
| 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: Multiplan Beech St/Commercial/PHCS |
$10.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.12
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION [5333]
|
Facility
|
OP
|
$14.04
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
1720545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.42
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.72
|
| 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 |
$8.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.10
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$6.21
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$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 |
$8.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.72
|
| 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 |
$7.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.40
|
|
|
NAFCILLIN 2 GRAM SOLUTION FOR INJECTION [5335]
|
Facility
|
OP
|
$26.40
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
1751022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$19.80 |
| 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 EPO/HMO/POS/PPO |
$15.62
|
| 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 |
$15.84
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Cash Price |
$11.88
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$20.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.84
|
| 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: LLUH Dept of Risk Management WC |
$14.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.00
|
|
|
NAFCILLIN 2 GRAM SOLUTION FOR INJECTION [5335]
|
Facility
|
IP
|
$26.40
|
|
|
Service Code
|
CPT S0032
|
| Hospital Charge Code |
1751022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$21.12 |
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.84
|
| 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: LLUH Dept of Risk Management WC |
$14.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.00
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
CPT J2300
|
| Hospital Charge Code |
1759515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.21
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
CPT J2300
|
| Hospital Charge Code |
1720255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.89 |
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.64
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
CPT J2300
|
| Hospital Charge Code |
1720255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.92
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.64
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
CPT J2300
|
| Hospital Charge Code |
1759515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.57
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.21
|
|
|
NALBUPHINE 20 MG/ML INJECTION SOLUTION [5340]
|
Facility
|
IP
|
$8.36
|
|
|
Service Code
|
CPT J2300
|
| Hospital Charge Code |
1720411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$6.69 |
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.27
|
|
|
NALBUPHINE 20 MG/ML INJECTION SOLUTION [5340]
|
Facility
|
OP
|
$8.36
|
|
|
Service Code
|
CPT J2300
|
| Hospital Charge Code |
1720411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$6.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.02
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.27
|
|
|
NALOXEGOL 12.5 MG TABLET [208811]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 57841-1300-1
|
| Hospital Charge Code |
ERX208811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$12.66 |
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 12.5 MG TABLET [208811]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 57841-1300-1
|
| Hospital Charge Code |
ERX208811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.50
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 57841-1301-3
|
| Hospital Charge Code |
ERX208812
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$12.66 |
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 57841-1301-3
|
| Hospital Charge Code |
ERX208812
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.50
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 57841-1301-1
|
| Hospital Charge Code |
ERX208812
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.50
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 82625-8802-1
|
| Hospital Charge Code |
ERX208812
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$12.66 |
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 57841-1301-1
|
| Hospital Charge Code |
ERX208812
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$12.66 |
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXEGOL 25 MG TABLET [208812]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 82625-8802-1
|
| Hospital Charge Code |
ERX208812
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.50
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.87
|
|
|
NALOXONE 1 MG/ML 2 ML SYRINGE - CODE [4080581]
|
Facility
|
OP
|
$19.80
|
|
|
Service Code
|
CPT J2310
|
| Hospital Charge Code |
1720711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$14.85 |
| 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 |
$8.91
|
| 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 Beech St/Commercial/PHCS |
$14.85
|
|
|
NALOXONE 1 MG/ML 2 ML SYRINGE - CODE [4080581]
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
CPT J2310
|
| Hospital Charge Code |
1720711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$15.84 |
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$14.85
|
|
|
NALOXONE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080435]
|
Facility
|
OP
|
$10.45
|
|
|
Service Code
|
NDC 9994-0804-35
|
| Hospital Charge Code |
1715254
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$7.84 |
| 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 |
$4.70
|
| 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 Beech St/Commercial/PHCS |
$7.84
|
|
