|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
NDC 62559-276-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.65
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Senior |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Senior |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.87
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 67877-392-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
NDC 62559-276-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.29
|
| Rate for Payer: Heritage Provider Network Senior |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 67877-392-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 43547-525-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 43547-525-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
NELARABINE 250 MG/50 ML INTRAVENOUS SOLUTION [70267]
|
Facility
|
IP
|
$15.86
|
|
|
Service Code
|
HCPCS J9261
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$11.89 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.34
|
| Rate for Payer: Heritage Provider Network Senior |
$7.34
|
| 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 |
$11.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.25
|
|
|
NELARABINE 250 MG/50 ML INTRAVENOUS SOLUTION [70267]
|
Facility
|
OP
|
$15.86
|
|
|
Service Code
|
HCPCS J9261
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$325.26 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$325.26
|
| Rate for Payer: Blue Shield of California Commercial |
$134.81
|
| Rate for Payer: Blue Shield of California EPN |
$134.81
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$79.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.72
|
| Rate for Payer: Dignity Health Senior |
$69.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$63.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.34
|
| Rate for Payer: Heritage Provider Network Senior |
$7.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$63.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.86
|
| Rate for Payer: Multiplan Commercial |
$11.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.34
|
| Rate for Payer: TriValley Medical Group Senior |
$6.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$79.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.72
|
| Rate for Payer: Vantage Medical Group Senior |
$69.72
|
|
|
NELFINAVIR 250 MG TABLET [20032]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 63010-010-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$3.29
|
| 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 |
$3.65
|
|
|
NELFINAVIR 250 MG TABLET [20032]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 63010-010-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.60
|
| 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 |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.37
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.16
|
| 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 |
$3.01
|
| Rate for Payer: Heritage Provider Network Senior |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.32
|
| 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: Molina Healthcare of CA Medi-Cal |
$3.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
| 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 |
$2.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
NEOMY-BACIT-POLYMYX-PRAMOXINE 3.5 MG-500 UNIT-10,000 UNIT/G TOP OINT [21070]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 0713-0622-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
NEOMY-BACIT-POLYMYX-PRAMOXINE 3.5 MG-500 UNIT-10,000 UNIT/G TOP OINT [21070]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 0713-0622-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS [5474]
|
Facility
|
OP
|
$6.13
|
|
|
Service Code
|
NDC 24208-790-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Adventist Health Commercial |
$1.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$2.99
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.21
|
| Rate for Payer: Dignity Health Senior |
$5.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.79
|
| Rate for Payer: Heritage Provider Network Senior |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$4.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.45
|
| Rate for Payer: TriValley Medical Group Senior |
$2.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.21
|
| Rate for Payer: Vantage Medical Group Senior |
$5.21
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS [5474]
|
Facility
|
IP
|
$6.13
|
|
|
Service Code
|
NDC 24208-790-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.23
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.15
|
| Rate for Payer: Heritage Provider Network Senior |
$4.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$4.60
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]
|
Facility
|
IP
|
$5.45
|
|
|
Service Code
|
NDC 24208-795-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Adventist Health Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.69
|
| Rate for Payer: Heritage Provider Network Senior |
$3.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$4.09
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]
|
Facility
|
OP
|
$6.17
|
|
|
Service Code
|
NDC 61314-631-36
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Adventist Health Commercial |
$1.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.63
|
| Rate for Payer: Blue Shield of California Commercial |
$3.76
|
| Rate for Payer: Blue Shield of California EPN |
$3.01
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.24
|
| Rate for Payer: Dignity Health Senior |
$5.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.82
|
| Rate for Payer: Heritage Provider Network Senior |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$4.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Senior |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.24
|
| Rate for Payer: Vantage Medical Group Senior |
$5.24
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]
|
Facility
|
IP
|
$6.17
|
|
|
Service Code
|
NDC 61314-631-36
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Adventist Health Commercial |
$1.23
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.63
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]
|
Facility
|
OP
|
$5.45
|
|
|
Service Code
|
NDC 24208-795-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Adventist Health Commercial |
$1.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.09
|
| Rate for Payer: Blue Shield of California Commercial |
$3.32
|
| Rate for Payer: Blue Shield of California EPN |
$2.66
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.63
|
| Rate for Payer: Dignity Health Senior |
$4.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.37
|
| Rate for Payer: Heritage Provider Network Senior |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.81
|
| Rate for Payer: Multiplan Commercial |
$4.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.18
|
| Rate for Payer: TriValley Medical Group Senior |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4.63
|
|
|
NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP [35126]
|
Facility
|
IP
|
$23.95
|
|
|
Service Code
|
NDC 61314-641-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$17.96 |
| Rate for Payer: Adventist Health Commercial |
$4.79
|
| Rate for Payer: Cash Price |
$13.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.21
|
| Rate for Payer: Heritage Provider Network Senior |
$16.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.99
|
| Rate for Payer: Multiplan Commercial |
$17.96
|
|
|
NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP [35126]
|
Facility
|
OP
|
$23.95
|
|
|
Service Code
|
NDC 61314-641-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Adventist Health Commercial |
$4.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.96
|
| Rate for Payer: Blue Shield of California Commercial |
$14.61
|
| Rate for Payer: Blue Shield of California EPN |
$11.69
|
| Rate for Payer: Cash Price |
$13.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.36
|
| Rate for Payer: Dignity Health Senior |
$20.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.83
|
| Rate for Payer: Heritage Provider Network Senior |
$14.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.77
|
| Rate for Payer: Multiplan Commercial |
$17.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.58
|
| Rate for Payer: TriValley Medical Group Senior |
$9.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.36
|
| Rate for Payer: Vantage Medical Group Senior |
$20.36
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]
|
Facility
|
OP
|
$13.11
|
|
|
Service Code
|
NDC 39822-1201-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Adventist Health Commercial |
$2.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.83
|
| Rate for Payer: Blue Shield of California Commercial |
$8.00
|
| Rate for Payer: Blue Shield of California EPN |
$6.40
|
| Rate for Payer: Cash Price |
$7.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.14
|
| Rate for Payer: Dignity Health Senior |
$11.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.18
|
| Rate for Payer: Multiplan Commercial |
$9.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Senior |
$5.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.14
|
| Rate for Payer: Vantage Medical Group Senior |
$11.14
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]
|
Facility
|
IP
|
$13.56
|
|
|
Service Code
|
NDC 39822-1201-5
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Adventist Health Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.18
|
| Rate for Payer: Heritage Provider Network Senior |
$9.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.39
|
| Rate for Payer: Multiplan Commercial |
$10.17
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]
|
Facility
|
OP
|
$13.56
|
|
|
Service Code
|
NDC 39822-1201-5
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$11.53 |
| Rate for Payer: Adventist Health Commercial |
$2.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.17
|
| Rate for Payer: Blue Shield of California Commercial |
$8.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.62
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.53
|
| Rate for Payer: Dignity Health Senior |
$11.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Senior |
$8.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.49
|
| Rate for Payer: Multiplan Commercial |
$10.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.42
|
| Rate for Payer: TriValley Medical Group Senior |
$5.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.53
|
| Rate for Payer: Vantage Medical Group Senior |
$11.53
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]
|
Facility
|
IP
|
$13.11
|
|
|
Service Code
|
NDC 39822-1201-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Adventist Health Commercial |
$2.62
|
| Rate for Payer: Cash Price |
$7.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.88
|
| Rate for Payer: Heritage Provider Network Senior |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Multiplan Commercial |
$9.83
|
|
|
NEOMYCIN 500 MG TABLET [5472]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 0093-1177-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Senior |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
