|
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 |
$0.88 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.32
|
| Rate for Payer: Blue Shield of California EPN |
$3.32
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.13
|
| Rate for Payer: Dignity Health Senior |
$4.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.94
|
| Rate for Payer: TriValley Medical Group Senior |
$1.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
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 |
$1.51 |
| Max. Negotiated Rate |
$6.27 |
| Rate for Payer: Adventist Health Commercial |
$1.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.74
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.66
|
| Rate for Payer: Heritage Provider Network Senior |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.09
|
| Rate for Payer: Multiplan Commercial |
$6.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.79
|
|
|
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 |
$1.51 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$1.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.32
|
| Rate for Payer: Blue Shield of California EPN |
$3.32
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.11
|
| Rate for Payer: Dignity Health Senior |
$7.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.09
|
| Rate for Payer: Multiplan Commercial |
$6.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.34
|
| Rate for Payer: TriValley Medical Group Senior |
$3.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.11
|
| Rate for Payer: Vantage Medical Group Senior |
$7.11
|
|
|
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 |
$2.87 |
| Max. Negotiated Rate |
$13.46 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.87
|
| Rate for Payer: Blue Shield of California Commercial |
$9.83
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.46
|
| Rate for Payer: Dignity Health Senior |
$13.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.80
|
| Rate for Payer: Heritage Provider Network Senior |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.33
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Vantage Medical Group Senior |
$13.46
|
|
|
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 |
$2.87 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Senior |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$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 |
$2.87 |
| Max. Negotiated Rate |
$13.46 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.87
|
| Rate for Payer: Blue Shield of California Commercial |
$9.83
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.46
|
| Rate for Payer: Dignity Health Senior |
$13.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.80
|
| Rate for Payer: Heritage Provider Network Senior |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.33
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Vantage Medical Group Senior |
$13.46
|
|
|
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 |
$2.87 |
| Max. Negotiated Rate |
$13.46 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.87
|
| Rate for Payer: Blue Shield of California Commercial |
$9.83
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.46
|
| Rate for Payer: Dignity Health Senior |
$13.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.80
|
| Rate for Payer: Heritage Provider Network Senior |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.33
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Vantage Medical Group Senior |
$13.46
|
|
|
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 |
$2.87 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Senior |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$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 |
$2.87 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Senior |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$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 |
$2.87 |
| Max. Negotiated Rate |
$13.46 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.87
|
| Rate for Payer: Blue Shield of California Commercial |
$9.83
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.46
|
| Rate for Payer: Dignity Health Senior |
$13.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.80
|
| Rate for Payer: Heritage Provider Network Senior |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$11.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.33
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Vantage Medical Group Senior |
$13.46
|
|
|
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 |
$2.87 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.88
|
| Rate for Payer: Cash Price |
$7.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Senior |
$10.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$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 |
$3.58 |
| Max. Negotiated Rate |
$18.33 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.45
|
| Rate for Payer: Blue Shield of California Commercial |
$15.99
|
| Rate for Payer: Blue Shield of California EPN |
$15.99
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.83
|
| Rate for Payer: Dignity Health Senior |
$16.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Senior |
$9.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.83
|
| Rate for Payer: Vantage Medical Group Senior |
$16.83
|
|
|
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 |
$3.58 |
| Max. Negotiated Rate |
$14.85 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.60
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.40
|
| Rate for Payer: Heritage Provider Network Senior |
$13.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.62
|
|
|
NALOXONE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080435]
|
Facility
|
IP
|
$10.45
|
|
|
Service Code
|
NDC 9994-0804-35
|
| Hospital Charge Code |
1715254
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$7.84 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.18
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
|
|
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 |
$1.89 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.84
|
| Rate for Payer: Blue Shield of California Commercial |
$6.49
|
| Rate for Payer: Blue Shield of California EPN |
$6.13
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.88
|
| Rate for Payer: Dignity Health Senior |
$8.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.47
|
| Rate for Payer: Heritage Provider Network Senior |
$6.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.18
|
| Rate for Payer: TriValley Medical Group Senior |
$4.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.88
|
| Rate for Payer: Vantage Medical Group Senior |
$8.88
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 47335-326-83
|
| Hospital Charge Code |
1711834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.41
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Senior |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 51224-206-30
|
| Hospital Charge Code |
1711834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 51224-206-30
|
| Hospital Charge Code |
1711834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Senior |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 0406-1170-03
|
| Hospital Charge Code |
1711834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 47335-326-83
|
| Hospital Charge Code |
1711834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 0406-1170-03
|
| Hospital Charge Code |
1711834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS [5384]
|
Facility
|
IP
|
$0.63
|
|
|
Service Code
|
NDC 0065-0085-15
|
| Hospital Charge Code |
1740213
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS [5384]
|
Facility
|
OP
|
$0.63
|
|
|
Service Code
|
NDC 0065-0085-15
|
| Hospital Charge Code |
1740213
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
NAPROXEN 250 MG TABLET [5391]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 50268-594-11
|
| Hospital Charge Code |
1711235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
NAPROXEN 250 MG TABLET [5391]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 50268-594-15
|
| Hospital Charge Code |
1711235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
