|
NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION [40120]
|
Facility
IP
|
$656.75
|
|
|
Service Code
|
CPT J2323
|
| Hospital Charge Code |
1720955
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.87 |
| Max. Negotiated Rate |
$492.56 |
| Rate for Payer: Adventist Health Commercial |
$131.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$451.19
|
| Rate for Payer: Cash Price |
$295.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$354.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$444.62
|
| Rate for Payer: Heritage Provider Network Senior |
$444.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$118.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.19
|
| Rate for Payer: Multiplan Commercial |
$492.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$239.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$219.42
|
|
|
NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION [40120]
|
Facility
OP
|
$656.75
|
|
|
Service Code
|
CPT J2323
|
| Hospital Charge Code |
1720955
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$492.56 |
| Rate for Payer: Adventist Health Commercial |
$131.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$451.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$30.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.21
|
| Rate for Payer: Blue Shield of California Commercial |
$26.71
|
| Rate for Payer: Blue Shield of California EPN |
$26.71
|
| Rate for Payer: Cash Price |
$295.54
|
| Rate for Payer: Cash Price |
$295.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.90
|
| Rate for Payer: Dignity Health Senior |
$26.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$420.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.08
|
| Rate for Payer: Heritage Provider Network Senior |
$304.08
|
| Rate for Payer: Humana Medicare |
$24.45
|
| Rate for Payer: IEHP Medi-Cal |
$45.10
|
| Rate for Payer: IEHP Medicare Advantage |
$24.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$118.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.81
|
| Rate for Payer: Multiplan Commercial |
$492.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$26.90
|
| Rate for Payer: TriValley Medical Group Senior |
$24.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$239.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$219.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.90
|
| Rate for Payer: Vantage Medical Group Senior |
$24.45
|
|
|
NATAMYCIN 5 % EYE DROPS,SUSPENSION [10692]
|
Facility
OP
|
$37.89
|
|
|
Service Code
|
NDC 71776-005-15
|
| Hospital Charge Code |
1740103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$32.21 |
| Rate for Payer: Adventist Health Commercial |
$7.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$28.42
|
| Rate for Payer: Blue Shield of California Commercial |
$23.53
|
| Rate for Payer: Blue Shield of California EPN |
$22.24
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.21
|
| Rate for Payer: Dignity Health Senior |
$32.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.45
|
| Rate for Payer: Heritage Provider Network Senior |
$23.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.47
|
| Rate for Payer: Multiplan Commercial |
$28.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.21
|
| Rate for Payer: Vantage Medical Group Senior |
$32.21
|
|
|
NATAMYCIN 5 % EYE DROPS,SUSPENSION [10692]
|
Facility
OP
|
$37.89
|
|
|
Service Code
|
NDC 0065-0645-15
|
| Hospital Charge Code |
1740103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$32.21 |
| Rate for Payer: Adventist Health Commercial |
$7.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$28.42
|
| Rate for Payer: Blue Shield of California Commercial |
$23.53
|
| Rate for Payer: Blue Shield of California EPN |
$22.24
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.21
|
| Rate for Payer: Dignity Health Senior |
$32.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.45
|
| Rate for Payer: Heritage Provider Network Senior |
$23.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.47
|
| Rate for Payer: Multiplan Commercial |
$28.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.21
|
| Rate for Payer: Vantage Medical Group Senior |
$32.21
|
|
|
NATAMYCIN 5 % EYE DROPS,SUSPENSION [10692]
|
Facility
IP
|
$37.89
|
|
|
Service Code
|
NDC 71776-005-15
|
| Hospital Charge Code |
1740103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$28.42 |
| Rate for Payer: Adventist Health Commercial |
$7.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.03
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.65
|
| Rate for Payer: Heritage Provider Network Senior |
$25.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.47
|
| Rate for Payer: Multiplan Commercial |
$28.42
|
|
|
NATAMYCIN 5 % EYE DROPS,SUSPENSION [10692]
|
Facility
IP
|
$37.89
|
|
|
Service Code
|
NDC 0065-0645-15
|
| Hospital Charge Code |
1740103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$28.42 |
| Rate for Payer: Adventist Health Commercial |
$7.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.03
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.65
|
| Rate for Payer: Heritage Provider Network Senior |
$25.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.47
|
| Rate for Payer: Multiplan Commercial |
$28.42
|
|
|
NATEGLINIDE 120 MG TABLET [29438]
|
Facility
IP
|
$2.39
|
|
|
Service Code
|
NDC 68084-459-21
|
| Hospital Charge Code |
1711806
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| 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 |
$1.79
|
|
|
NATEGLINIDE 120 MG TABLET [29438]
|
Facility
IP
|
$2.39
|
|
|
Service Code
|
NDC 68084-459-11
|
| Hospital Charge Code |
1711806
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| 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 |
$1.79
|
|
|
NATEGLINIDE 120 MG TABLET [29438]
|
Facility
OP
|
$2.39
|
|
|
Service Code
|
NDC 68084-459-11
|
| Hospital Charge Code |
1711806
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.03 |
| 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 |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Senior |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.15
|
| 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 |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
NATEGLINIDE 120 MG TABLET [29438]
|
Facility
OP
|
$2.39
|
|
|
Service Code
|
NDC 68084-459-21
|
| Hospital Charge Code |
1711806
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.03 |
| 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 |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Senior |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.15
|
| 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 |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
NATEGLINIDE 60 MG TABLET [29437]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
NDC 68084-458-11
|
| Hospital Charge Code |
1711805
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
NATEGLINIDE 60 MG TABLET [29437]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 68084-458-11
|
| Hospital Charge Code |
1711805
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
NAXITAMAB-GQGK 4 MG/ML INTRAVENOUS SOLUTION [229812]
|
Facility
IP
|
$2,770.88
|
|
|
Service Code
|
CPT J9348
|
| Hospital Charge Code |
NDG229812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$501.53 |
| Max. Negotiated Rate |
$2,078.16 |
| Rate for Payer: Adventist Health Commercial |
$554.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,903.59
|
| Rate for Payer: Cash Price |
$1,246.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,274.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,496.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,875.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1,875.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$501.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$692.72
|
| Rate for Payer: Multiplan Commercial |
$2,078.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,010.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$925.75
|
|
|
NAXITAMAB-GQGK 4 MG/ML INTRAVENOUS SOLUTION [229812]
|
Facility
OP
|
$2,770.88
|
|
|
Service Code
|
CPT J9348
|
| Hospital Charge Code |
NDG229812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$501.53 |
| Max. Negotiated Rate |
$2,078.16 |
| Rate for Payer: Adventist Health Commercial |
$554.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,497.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,903.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$762.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$670.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$670.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,126.27
|
| Rate for Payer: Blue Shield of California Commercial |
$559.44
|
| Rate for Payer: Blue Shield of California EPN |
$559.44
|
| Rate for Payer: Cash Price |
$1,246.90
|
| Rate for Payer: Cash Price |
$1,246.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,274.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$762.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$670.74
|
| Rate for Payer: Dignity Health Senior |
$670.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,773.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$609.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,282.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,282.92
|
| Rate for Payer: Humana Medicare |
$609.76
|
| Rate for Payer: IEHP Medi-Cal |
$958.20
|
| Rate for Payer: IEHP Medicare Advantage |
$609.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,158.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$501.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$719.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$692.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$768.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$768.30
|
| Rate for Payer: Multiplan Commercial |
$2,078.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$670.74
|
| Rate for Payer: TriValley Medical Group Senior |
$609.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,010.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$925.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$762.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$670.74
|
| Rate for Payer: Vantage Medical Group Senior |
$670.74
|
|
|
NEBIVOLOL 10 MG TABLET [89286]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 43547-526-03
|
| Hospital Charge Code |
1712399
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare 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 |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| 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: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
NEBIVOLOL 10 MG TABLET [89286]
|
Facility
IP
|
$0.56
|
|
|
Service Code
|
NDC 67877-391-30
|
| Hospital Charge Code |
1712399
|
|
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: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| 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 10 MG TABLET [89286]
|
Facility
OP
|
$0.56
|
|
|
Service Code
|
NDC 67877-391-30
|
| Hospital Charge Code |
1712399
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.25
|
| 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: Multiplan Commercial |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
NEBIVOLOL 10 MG TABLET [89286]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 43547-526-03
|
| Hospital Charge Code |
1712399
|
|
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: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| 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
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
OP
|
$6.96
|
|
|
Service Code
|
NDC 0456-1405-30
|
| Hospital Charge Code |
1712386
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.92 |
| Rate for Payer: Adventist Health Commercial |
$1.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.22
|
| Rate for Payer: Blue Shield of California Commercial |
$4.32
|
| Rate for Payer: Blue Shield of California EPN |
$4.09
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.92
|
| Rate for Payer: Dignity Health Senior |
$5.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.31
|
| Rate for Payer: Heritage Provider Network Senior |
$4.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$5.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.92
|
| Rate for Payer: Vantage Medical Group Senior |
$5.92
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 43547-525-03
|
| Hospital Charge Code |
1712386
|
|
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: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| 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
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
IP
|
$6.96
|
|
|
Service Code
|
NDC 0456-1405-30
|
| Hospital Charge Code |
1712386
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Adventist Health Commercial |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.78
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.71
|
| Rate for Payer: Heritage Provider Network Senior |
$4.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$5.22
|
|
|
NEBIVOLOL 5 MG TABLET [89284]
|
Facility
OP
|
$3.38
|
|
|
Service Code
|
NDC 62559-276-30
|
| Hospital Charge Code |
1712386
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.10
|
| Rate for Payer: Blue Shield of California EPN |
$1.98
|
| Rate for Payer: Cash Price |
$1.52
|
| 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 |
$1.63
|
| 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
|
| 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 |
1712386
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.25
|
| 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: Multiplan Commercial |
$0.42
|
| 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
|
$0.56
|
|
|
Service Code
|
NDC 67877-392-30
|
| Hospital Charge Code |
1712386
|
|
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: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| 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 |
1712386
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare 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 |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| 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: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
