|
NORETHINDRONE ACETATE 5 MG TABLET [10747]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 68462-304-50
|
| Hospital Charge Code |
1710200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
|
|
NORETHINDRONE ACETATE 5 MG TABLET [10747]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
NDC 0555-0211-10
|
| Hospital Charge Code |
1710200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.67
|
|
|
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET [19743]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0378-7292-85
|
| Hospital Charge Code |
1712602
|
|
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
|
|
|
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET [19743]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0378-7292-53
|
| Hospital Charge Code |
1712602
|
|
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
|
|
|
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET [19743]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0378-7292-53
|
| Hospital Charge Code |
1712602
|
|
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
|
|
|
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET [19743]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0378-7292-85
|
| Hospital Charge Code |
1712602
|
|
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
|
|
|
NORETHINDRONE-E.ESTRADIOL TRIPHASIC 0.5 MG/0.75 MG/1 MG-35 MCG TABLET [10738]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 0555-9012-58
|
| Hospital Charge Code |
ERX10738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.70
|
|
|
NORETHINDRONE-E.ESTRADIOL TRIPHASIC 0.5 MG/0.75 MG/1 MG-35 MCG TABLET [10738]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 0555-9012-58
|
| Hospital Charge Code |
ERX10738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.70
|
|
|
NORETHINDRONE-ETHINYL ESTRADIOL TRIPHASIC 0.5/1/0.5 MG-35 MCG TABLET [10739]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 0555-9066-79
|
| Hospital Charge Code |
1711354
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.91
|
|
|
NORETHINDRONE-ETHINYL ESTRADIOL TRIPHASIC 0.5/1/0.5 MG-35 MCG TABLET [10739]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 0555-9066-79
|
| Hospital Charge Code |
1711354
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.91
|
|
|
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY [39802]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 386000404
|
| Hospital Charge Code |
NDG39802
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY [39802]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 386000404
|
| Hospital Charge Code |
NDG39802
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
NORGESTREL 0.3 MG-ETHINYL ESTRADIOL 30 MCG TABLET [10752]
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 0555-9049-58
|
| Hospital Charge Code |
ERX10752
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
NORGESTREL 0.3 MG-ETHINYL ESTRADIOL 30 MCG TABLET [10752]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 0555-9049-58
|
| Hospital Charge Code |
ERX10752
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 51672-4001-1
|
| Hospital Charge Code |
1710151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 51672-4001-5
|
| Hospital Charge Code |
1710151
|
|
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
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 60687-281-11
|
| Hospital Charge Code |
1710151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 60687-281-01
|
| Hospital Charge Code |
1710151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 51672-4001-5
|
| Hospital Charge Code |
1710151
|
|
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
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 60687-281-11
|
| Hospital Charge Code |
1710151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 51672-4001-1
|
| Hospital Charge Code |
1710151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 60687-281-01
|
| Hospital Charge Code |
1710151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 50268-604-11
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 0093-0811-01
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.24
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 51672-4002-1
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.24
|
|
