|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0904-0734-31
|
| Hospital Charge Code |
1743560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$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 45802-143-70
|
| Hospital Charge Code |
1743128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
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 |
$0.91 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.27
|
| Rate for Payer: Blue Distinction Transplant |
$2.29
|
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO |
$2.67
|
| Rate for Payer: Cigna of CA PPO |
$2.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.24
|
| Rate for Payer: Dignity Health Media |
$3.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.52
|
| Rate for Payer: Galaxy Health WC |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$2.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.05
|
| Rate for Payer: Networks By Design Commercial |
$2.48
|
| Rate for Payer: Prime Health Services Commercial |
$3.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.90
|
| Rate for Payer: United Healthcare All Other HMO |
$1.90
|
| Rate for Payer: United Healthcare HMO Rider |
$1.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.24
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.91 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Blue Shield of California Commercial |
$2.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.95
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO |
$2.67
|
| Rate for Payer: Cigna of CA PPO |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Galaxy Health WC |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.05
|
| Rate for Payer: Networks By Design Commercial |
$2.48
|
| Rate for Payer: Prime Health Services Commercial |
$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 |
$1.04 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.57
|
| Rate for Payer: Blue Distinction Transplant |
$2.59
|
| Rate for Payer: Blue Shield of California Commercial |
$3.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Media |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO |
$2.16
|
| Rate for Payer: United Healthcare HMO Rider |
$2.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
|
|
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 |
$1.04 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Blue Shield of California Commercial |
$3.08
|
| Rate for Payer: Blue Shield of California EPN |
$2.21
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
|
|
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 |
$2.42 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.00
|
| Rate for Payer: Blue Distinction Transplant |
$6.04
|
| Rate for Payer: Blue Shield of California Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.88
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO |
$7.05
|
| Rate for Payer: Cigna of CA PPO |
$7.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.56
|
| Rate for Payer: Dignity Health Media |
$8.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.03
|
| Rate for Payer: Galaxy Health WC |
$8.56
|
| Rate for Payer: Global Benefits Group Commercial |
$6.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$8.06
|
| Rate for Payer: Networks By Design Commercial |
$6.55
|
| Rate for Payer: Prime Health Services Commercial |
$8.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.04
|
| Rate for Payer: United Healthcare All Other HMO |
$5.04
|
| Rate for Payer: United Healthcare HMO Rider |
$5.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.56
|
| Rate for Payer: Vantage Medical Group Senior |
$8.56
|
|
|
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 |
$2.42 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Blue Shield of California Commercial |
$7.17
|
| Rate for Payer: Blue Shield of California EPN |
$5.16
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO |
$7.05
|
| Rate for Payer: Cigna of CA PPO |
$7.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Galaxy Health WC |
$8.56
|
| Rate for Payer: Global Benefits Group Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$8.06
|
| Rate for Payer: Networks By Design Commercial |
$6.55
|
| Rate for Payer: Prime Health Services Commercial |
$8.56
|
|
|
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 |
$2.42 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.00
|
| Rate for Payer: Blue Distinction Transplant |
$6.04
|
| Rate for Payer: Blue Shield of California Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.88
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO |
$7.05
|
| Rate for Payer: Cigna of CA PPO |
$7.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.56
|
| Rate for Payer: Dignity Health Media |
$8.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.03
|
| Rate for Payer: Galaxy Health WC |
$8.56
|
| Rate for Payer: Global Benefits Group Commercial |
$6.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$8.06
|
| Rate for Payer: Networks By Design Commercial |
$6.55
|
| Rate for Payer: Prime Health Services Commercial |
$8.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.04
|
| Rate for Payer: United Healthcare All Other HMO |
$5.04
|
| Rate for Payer: United Healthcare HMO Rider |
$5.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.56
|
| Rate for Payer: Vantage Medical Group Senior |
$8.56
|
|
|
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 |
$2.42 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.00
|
| Rate for Payer: Blue Distinction Transplant |
$6.04
|
| Rate for Payer: Blue Shield of California Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.88
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO |
$7.05
|
| Rate for Payer: Cigna of CA PPO |
$7.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.56
|
| Rate for Payer: Dignity Health Media |
$8.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.03
|
| Rate for Payer: Galaxy Health WC |
$8.56
|
| Rate for Payer: Global Benefits Group Commercial |
$6.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$8.06
|
| Rate for Payer: Networks By Design Commercial |
$6.55
|
| Rate for Payer: Prime Health Services Commercial |
$8.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.04
|
| Rate for Payer: United Healthcare All Other HMO |
$5.04
|
| Rate for Payer: United Healthcare HMO Rider |
$5.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.56
|
| Rate for Payer: Vantage Medical Group Senior |
$8.56
|
|
|
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 |
$2.42 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Blue Shield of California Commercial |
$7.17
|
| Rate for Payer: Blue Shield of California EPN |
$5.16
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO |
$7.05
|
| Rate for Payer: Cigna of CA PPO |
$7.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Galaxy Health WC |
$8.56
|
| Rate for Payer: Global Benefits Group Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$8.06
|
| Rate for Payer: Networks By Design Commercial |
$6.55
|
| Rate for Payer: Prime Health Services Commercial |
$8.56
|
|
|
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 |
$2.42 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Blue Shield of California Commercial |
$7.17
|
| Rate for Payer: Blue Shield of California EPN |
$5.16
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna of CA HMO |
$7.05
|
| Rate for Payer: Cigna of CA PPO |
$7.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Galaxy Health WC |
$8.56
|
| Rate for Payer: Global Benefits Group Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$8.06
|
| Rate for Payer: Networks By Design Commercial |
$6.55
|
| Rate for Payer: Prime Health Services Commercial |
$8.56
|
|
|
NEONATAL AFTERCARE
|
Facility
|
IP
|
$84,117.43
|
|
|
Service Code
|
APR-DRG 8633
|
| Min. Negotiated Rate |
$64,526.92 |
| Max. Negotiated Rate |
$84,117.43 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$64,526.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84,117.43
|
|
|
NEONATAL AFTERCARE
|
Facility
|
IP
|
$188,781.99
|
|
|
Service Code
|
APR-DRG 8634
|
| Min. Negotiated Rate |
$144,815.66 |
| Max. Negotiated Rate |
$188,781.99 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$144,815.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$188,781.99
|
|
|
NEONATAL AFTERCARE
|
Facility
|
IP
|
$16,965.37
|
|
|
Service Code
|
APR-DRG 8631
|
| Min. Negotiated Rate |
$13,014.22 |
| Max. Negotiated Rate |
$16,965.37 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,014.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,965.37
|
|
|
NEONATAL AFTERCARE
|
Facility
|
IP
|
$43,159.37
|
|
|
Service Code
|
APR-DRG 8632
|
| Min. Negotiated Rate |
$33,107.78 |
| Max. Negotiated Rate |
$43,159.37 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33,107.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43,159.37
|
|
|
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION
|
Facility
|
IP
|
$2,994.93
|
|
|
Service Code
|
APR-DRG 6031
|
| Min. Negotiated Rate |
$2,297.43 |
| Max. Negotiated Rate |
$2,994.93 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,297.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,994.93
|
|
|
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION
|
Facility
|
IP
|
$369,963.27
|
|
|
Service Code
|
APR-DRG 6034
|
| Min. Negotiated Rate |
$283,800.77 |
| Max. Negotiated Rate |
$369,963.27 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$283,800.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$369,963.27
|
|
