|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0904-0734-31
|
| Hospital Charge Code |
1743560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 0713-0268-31
|
| Hospital Charge Code |
1743560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 45802-143-03
|
| Hospital Charge Code |
1743560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 68001-483-45
|
| Hospital Charge Code |
1743560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 45802-143-01
|
| Hospital Charge Code |
1743108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 68001-483-45
|
| Hospital Charge Code |
1743560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6680-67
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 45802-143-70
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 45802-061-70
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 47682-223-35
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 47682-223-35
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 45802-061-70
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 45802-143-70
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [118303]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6680-67
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 61314-630-06
|
| Hospital Charge Code |
1740080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.24
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 61314-630-06
|
| Hospital Charge Code |
1740080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.59
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.24
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]
|
Facility
|
IP
|
$3.81
|
|
|
Service Code
|
NDC 24208-830-60
|
| Hospital Charge Code |
1740080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.86
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]
|
Facility
|
OP
|
$3.81
|
|
|
Service Code
|
NDC 24208-830-60
|
| Hospital Charge Code |
1740080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.29
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.86
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]
|
Facility
|
IP
|
$10.07
|
|
|
Service Code
|
NDC 24208-635-62
|
| Hospital Charge Code |
1740060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$8.06 |
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.55
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]
|
Facility
|
OP
|
$10.07
|
|
|
Service Code
|
NDC 24208-635-62
|
| Hospital Charge Code |
1740060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$7.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.04
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.55
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]
|
Facility
|
OP
|
$10.07
|
|
|
Service Code
|
NDC 24208-631-10
|
| Hospital Charge Code |
1740064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$7.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.04
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.55
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]
|
Facility
|
OP
|
$10.07
|
|
|
Service Code
|
NDC 61314-646-10
|
| Hospital Charge Code |
1740064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$7.55 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.04
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.55
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]
|
Facility
|
IP
|
$10.07
|
|
|
Service Code
|
NDC 61314-646-10
|
| Hospital Charge Code |
1740064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$8.06 |
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.55
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]
|
Facility
|
IP
|
$10.07
|
|
|
Service Code
|
NDC 24208-631-10
|
| Hospital Charge Code |
1740064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$8.06 |
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.55
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML INJECTION SOLUTION. [4085490]
|
Facility
|
OP
|
$3.02
|
|
|
Service Code
|
CPT J2710
|
| Hospital Charge Code |
NDG120692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.81
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.26
|
|
