|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 60687-293-01
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 60687-293-11
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 60687-293-11
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 51672-4002-1
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.24 |
| 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
|
$0.59
|
|
|
Service Code
|
NDC 50268-604-15
|
| 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
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 0093-0811-01
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| 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
|
|
|
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
|
$0.59
|
|
|
Service Code
|
NDC 50268-604-11
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$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
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 60687-293-01
|
| Hospital Charge Code |
1710171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
NUSINERSEN (PF) 12 MG/5 ML INTRATHECAL SOLUTION [216584]
|
Facility
|
OP
|
$31,977.00
|
|
|
Service Code
|
CPT J2326
|
| Hospital Charge Code |
NDG4081651
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17,587.35 |
| Max. Negotiated Rate |
$23,982.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$19,186.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$19,186.20
|
| Rate for Payer: Cash Price |
$14,389.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$19,186.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$19,186.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17,587.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23,982.75
|
|
|
NUSINERSEN (PF) 12 MG/5 ML INTRATHECAL SOLUTION [216584]
|
Facility
|
IP
|
$31,977.00
|
|
|
Service Code
|
CPT J2326
|
| Hospital Charge Code |
NDG4081651
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17,587.35 |
| Max. Negotiated Rate |
$25,581.60 |
| Rate for Payer: Cash Price |
$14,389.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25,581.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$19,186.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17,587.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23,982.75
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 45802-059-35
|
| Hospital Charge Code |
1743425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 45802-059-11
|
| Hospital Charge Code |
1743426
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 0713-0678-15
|
| Hospital Charge Code |
1743425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.78
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 51672-1289-1
|
| Hospital Charge Code |
1743425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 45802-059-35
|
| Hospital Charge Code |
1743425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 51672-1289-1
|
| Hospital Charge Code |
1743425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 0713-0678-15
|
| Hospital Charge Code |
1743425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.78
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 45802-059-11
|
| Hospital Charge Code |
1743426
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 51672-1289-2
|
| Hospital Charge Code |
1743426
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 0713-0678-31
|
| Hospital Charge Code |
1743426
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.60
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 51672-1289-2
|
| Hospital Charge Code |
1743426
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 0713-0678-31
|
| Hospital Charge Code |
1743426
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.60
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
NDC 72578-089-04
|
| Hospital Charge Code |
1743427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.57
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 45802-048-11
|
| Hospital Charge Code |
1743427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
