|
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
|
|
|
Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters
|
Facility
OP
|
$946.58
|
|
|
Service Code
|
CPT 97608
|
| Min. Negotiated Rate |
$498.20 |
| Max. Negotiated Rate |
$946.58 |
| Rate for Payer: Aetna of CA Gatekeeper |
$510.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
|
Facility
OP
|
$946.58
|
|
|
Service Code
|
CPT 97607
|
| Min. Negotiated Rate |
$387.49 |
| Max. Negotiated Rate |
$946.58 |
| Rate for Payer: Aetna of CA Gatekeeper |
$387.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
NELARABINE 250 MG/50 ML INTRAVENOUS SOLUTION [70267]
|
Facility
IP
|
$15.86
|
|
|
Service Code
|
CPT J9261
|
| Hospital Charge Code |
1755714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.90
|
| Rate for Payer: Cash Price |
$7.14
|
| 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 |
$10.74
|
| Rate for Payer: Heritage Provider Network Senior |
$10.74
|
| 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 |
$11.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.30
|
|
|
NELARABINE 250 MG/50 ML INTRAVENOUS SOLUTION [70267]
|
Facility
OP
|
$15.86
|
|
|
Service Code
|
CPT J9261
|
| Hospital Charge Code |
1755714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$218.58 |
| Rate for Payer: Adventist Health Commercial |
$3.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$218.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$138.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$122.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$122.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$178.13
|
| Rate for Payer: Blue Shield of California Commercial |
$134.84
|
| Rate for Payer: Blue Shield of California EPN |
$134.84
|
| Rate for Payer: Cash Price |
$7.14
|
| Rate for Payer: Cash Price |
$7.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$166.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$122.08
|
| Rate for Payer: Dignity Health Senior |
$122.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$110.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.34
|
| Rate for Payer: Heritage Provider Network Senior |
$7.34
|
| Rate for Payer: Humana Medicare |
$110.98
|
| Rate for Payer: IEHP Medi-Cal |
$180.09
|
| Rate for Payer: IEHP Medicare Advantage |
$110.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$210.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$130.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$139.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139.84
|
| Rate for Payer: Multiplan Commercial |
$11.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$122.08
|
| Rate for Payer: TriValley Medical Group Senior |
$110.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$166.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$122.08
|
| Rate for Payer: Vantage Medical Group Senior |
$110.98
|
|
|
NELFINAVIR 250 MG TABLET [20032]
|
Facility
IP
|
$4.86
|
|
|
Service Code
|
NDC 63010-010-30
|
| Hospital Charge Code |
1712238
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.34
|
| Rate for Payer: Cash Price |
$2.19
|
| 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 |
$3.64
|
|
|
NELFINAVIR 250 MG TABLET [20032]
|
Facility
OP
|
$4.86
|
|
|
Service Code
|
NDC 63010-010-30
|
| Hospital Charge Code |
1712238
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.64
|
| Rate for Payer: Blue Shield of California Commercial |
$3.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.85
|
| Rate for Payer: Cash Price |
$2.19
|
| 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 |
$2.34
|
| 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: 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
IP
|
$0.15
|
|
|
Service Code
|
NDC 0713-0622-31
|
| Hospital Charge Code |
NDG21070C
|
|
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: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| 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
|
|
|
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 |
NDG21070C
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| 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: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
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 |
1740124
|
|
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: Aetna of CA Non-Gatekeeper |
$4.21
|
| Rate for Payer: Cash Price |
$2.76
|
| 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 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 |
1740124
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$5.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.81
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$2.76
|
| 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 |
$2.95
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.21
|
| Rate for Payer: Vantage Medical Group Senior |
$5.21
|
|
|
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 |
1740083
|
|
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: Aetna of CA Non-Gatekeeper |
$3.74
|
| Rate for Payer: Cash Price |
$2.45
|
| 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
|
$5.45
|
|
|
Service Code
|
NDC 24208-795-35
|
| Hospital Charge Code |
1740083
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$4.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.09
|
| Rate for Payer: Blue Shield of California Commercial |
$3.38
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$2.45
|
| 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 |
$2.63
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4.63
|
|
|
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 |
1740083
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$5.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.63
|
| Rate for Payer: Blue Shield of California Commercial |
$3.83
|
| Rate for Payer: Blue Shield of California EPN |
$3.62
|
| Rate for Payer: Cash Price |
$2.78
|
| 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 |
$2.97
|
| 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
|
| 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 |
1740083
|
|
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: Aetna of CA Non-Gatekeeper |
$4.24
|
| Rate for Payer: Cash Price |
$2.78
|
| 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-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP [35126]
|
Facility
OP
|
$21.79
|
|
|
Service Code
|
NDC 61314-641-75
|
| Hospital Charge Code |
1740204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$18.52 |
| Rate for Payer: Adventist Health Commercial |
$4.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.34
|
| Rate for Payer: Blue Shield of California Commercial |
$13.53
|
| Rate for Payer: Blue Shield of California EPN |
$12.79
|
| Rate for Payer: Cash Price |
$9.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.52
|
| Rate for Payer: Dignity Health Senior |
$18.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.49
|
| Rate for Payer: Heritage Provider Network Senior |
$13.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.45
|
| Rate for Payer: Multiplan Commercial |
$16.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.52
|
| Rate for Payer: Vantage Medical Group Senior |
$18.52
|
|
|
NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP [35126]
|
Facility
IP
|
$21.79
|
|
|
Service Code
|
NDC 61314-641-75
|
| Hospital Charge Code |
1740204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Adventist Health Commercial |
$4.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.97
|
| Rate for Payer: Cash Price |
$9.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.75
|
| Rate for Payer: Heritage Provider Network Senior |
$14.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.45
|
| Rate for Payer: Multiplan Commercial |
$16.34
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]
|
Facility
IP
|
$12.33
|
|
|
Service Code
|
NDC 39822-1201-5
|
| Hospital Charge Code |
1756001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$9.25 |
| Rate for Payer: Adventist Health Commercial |
$2.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.47
|
| Rate for Payer: Cash Price |
$5.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Senior |
$8.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$9.25
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]
|
Facility
OP
|
$12.33
|
|
|
Service Code
|
NDC 39822-1201-5
|
| Hospital Charge Code |
1756001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$10.48 |
| Rate for Payer: Adventist Health Commercial |
$2.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.25
|
| Rate for Payer: Blue Shield of California Commercial |
$7.66
|
| Rate for Payer: Blue Shield of California EPN |
$7.24
|
| Rate for Payer: Cash Price |
$5.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.48
|
| Rate for Payer: Dignity Health Senior |
$10.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.63
|
| Rate for Payer: Heritage Provider Network Senior |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$9.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.48
|
| Rate for Payer: Vantage Medical Group Senior |
$10.48
|
|
|
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 |
1756001
|
|
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: Aetna of CA Non-Gatekeeper |
$9.01
|
| Rate for Payer: Cash Price |
$5.90
|
| 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 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 |
1756001
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$11.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.83
|
| Rate for Payer: Blue Shield of California Commercial |
$8.14
|
| Rate for Payer: Blue Shield of California EPN |
$7.70
|
| Rate for Payer: Cash Price |
$5.90
|
| 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 |
$6.32
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.14
|
| Rate for Payer: Vantage Medical Group Senior |
$11.14
|
|
|
NEOMYCIN 500 MG TABLET [5472]
|
Facility
OP
|
$1.33
|
|
|
Service Code
|
NDC 0093-1177-01
|
| Hospital Charge Code |
1711310
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| 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 |
$0.64
|
| 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: Multiplan Commercial |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
NEOMYCIN 500 MG TABLET [5472]
|
Facility
IP
|
$1.33
|
|
|
Service Code
|
NDC 0093-1177-01
|
| Hospital Charge Code |
1711310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| 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: Multiplan Commercial |
$1.00
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT [849]
|
Facility
IP
|
$17.84
|
|
|
Service Code
|
NDC 24208-785-55
|
| Hospital Charge Code |
1740051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$13.38 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.26
|
| Rate for Payer: Cash Price |
$8.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.08
|
| Rate for Payer: Heritage Provider Network Senior |
$12.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Multiplan Commercial |
$13.38
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT [849]
|
Facility
OP
|
$17.84
|
|
|
Service Code
|
NDC 24208-785-55
|
| Hospital Charge Code |
1740051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$15.16 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.38
|
| Rate for Payer: Blue Shield of California Commercial |
$11.08
|
| Rate for Payer: Blue Shield of California EPN |
$10.47
|
| Rate for Payer: Cash Price |
$8.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.16
|
| Rate for Payer: Dignity Health Senior |
$15.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.04
|
| Rate for Payer: Heritage Provider Network Senior |
$11.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Multiplan Commercial |
$13.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.16
|
| Rate for Payer: Vantage Medical Group Senior |
$15.16
|
|
