|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
OP
|
$55.60
|
|
|
Service Code
|
NDC 0069-5321-03
|
| Hospital Charge Code |
ERX408122221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$47.26 |
| Rate for Payer: Adventist Health Commercial |
$11.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$29.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41.70
|
| Rate for Payer: Blue Shield of California Commercial |
$34.53
|
| Rate for Payer: Blue Shield of California EPN |
$32.64
|
| Rate for Payer: Cash Price |
$25.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.26
|
| Rate for Payer: Dignity Health Senior |
$47.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.42
|
| Rate for Payer: Heritage Provider Network Senior |
$34.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.90
|
| Rate for Payer: Multiplan Commercial |
$41.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.26
|
| Rate for Payer: Vantage Medical Group Senior |
$47.26
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0069-1085-06
|
| Hospital Charge Code |
ERX408122221
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0069-1085-30
|
| Hospital Charge Code |
ERX408122221
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [408122221]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0069-1085-30
|
| Hospital Charge Code |
ERX408122221
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE [239073]
|
Facility
OP
|
$594.00
|
|
|
Service Code
|
CPT 90381
|
| Hospital Charge Code |
NDG239073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.51 |
| Max. Negotiated Rate |
$1,228.07 |
| Rate for Payer: Adventist Health Commercial |
$118.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,228.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$504.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$326.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$445.50
|
| Rate for Payer: Blue Shield of California Commercial |
$368.87
|
| Rate for Payer: Blue Shield of California EPN |
$348.68
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$504.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$504.90
|
| Rate for Payer: Dignity Health Senior |
$504.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$380.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.02
|
| Rate for Payer: Heritage Provider Network Senior |
$275.02
|
| Rate for Payer: IEHP Medi-Cal |
$779.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$286.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.50
|
| Rate for Payer: Multiplan Commercial |
$445.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$216.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$504.90
|
| Rate for Payer: Vantage Medical Group Senior |
$504.90
|
|
|
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE [239073]
|
Facility
IP
|
$594.00
|
|
|
Service Code
|
CPT 90381
|
| Hospital Charge Code |
NDG239073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.51 |
| Max. Negotiated Rate |
$445.50 |
| Rate for Payer: Adventist Health Commercial |
$118.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.08
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$320.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$402.14
|
| Rate for Payer: Heritage Provider Network Senior |
$402.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.50
|
| Rate for Payer: Multiplan Commercial |
$445.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$216.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.46
|
|
|
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE [239072]
|
Facility
IP
|
$1,188.00
|
|
|
Service Code
|
CPT 90380
|
| Hospital Charge Code |
NDG239072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$215.03 |
| Max. Negotiated Rate |
$891.00 |
| Rate for Payer: Adventist Health Commercial |
$237.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$816.16
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$546.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$641.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$804.28
|
| Rate for Payer: Heritage Provider Network Senior |
$804.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$215.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.00
|
| Rate for Payer: Multiplan Commercial |
$891.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$433.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$396.91
|
|
|
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE [239072]
|
Facility
OP
|
$1,188.00
|
|
|
Service Code
|
CPT 90380
|
| Hospital Charge Code |
NDG239072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$215.03 |
| Max. Negotiated Rate |
$1,228.07 |
| Rate for Payer: Adventist Health Commercial |
$237.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,228.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$816.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,009.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$653.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$891.00
|
| Rate for Payer: Blue Shield of California Commercial |
$737.75
|
| Rate for Payer: Blue Shield of California EPN |
$697.36
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$546.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,009.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,009.80
|
| Rate for Payer: Dignity Health Senior |
$1,009.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$760.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$550.04
|
| Rate for Payer: Heritage Provider Network Senior |
$550.04
|
| Rate for Payer: IEHP Medi-Cal |
$779.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$572.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$215.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.00
|
| Rate for Payer: Multiplan Commercial |
$891.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$433.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$396.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,009.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,009.80
|
|
|
NITAZOXANIDE 100 MG/5 ML ORAL SUSPENSION [34708]
|
Facility
IP
|
$10.44
|
|
|
Service Code
|
NDC 67546-212-21
|
| Hospital Charge Code |
1715312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$7.83 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.17
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$7.83
|
|
|
NITAZOXANIDE 100 MG/5 ML ORAL SUSPENSION [34708]
|
Facility
OP
|
$10.44
|
|
|
Service Code
|
NDC 67546-212-21
|
| Hospital Charge Code |
1715312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$8.87 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.83
|
| Rate for Payer: Blue Shield of California Commercial |
$6.48
|
| Rate for Payer: Blue Shield of California EPN |
$6.13
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.87
|
| Rate for Payer: Dignity Health Senior |
$8.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.46
|
| Rate for Payer: Heritage Provider Network Senior |
$6.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$7.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.87
|
| Rate for Payer: Vantage Medical Group Senior |
$8.87
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
OP
|
$161.56
|
|
|
Service Code
|
NDC 67546-111-12
|
| Hospital Charge Code |
1711963
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.24 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Adventist Health Commercial |
$32.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$110.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$137.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$88.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$121.17
|
| Rate for Payer: Blue Shield of California Commercial |
$100.33
|
| Rate for Payer: Blue Shield of California EPN |
$94.84
|
| Rate for Payer: Cash Price |
$72.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$137.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$137.33
|
| Rate for Payer: Dignity Health Senior |
$137.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.01
|
| Rate for Payer: Heritage Provider Network Senior |
$100.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.39
|
| Rate for Payer: Multiplan Commercial |
$121.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$137.33
|
| Rate for Payer: Vantage Medical Group Senior |
$137.33
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
IP
|
$70.25
|
|
|
Service Code
|
NDC 64980-526-21
|
| Hospital Charge Code |
1711963
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$52.69 |
| Rate for Payer: Adventist Health Commercial |
$14.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.26
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.56
|
| Rate for Payer: Heritage Provider Network Senior |
$47.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.56
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
IP
|
$173.90
|
|
|
Service Code
|
NDC 67546-111-14
|
| Hospital Charge Code |
1711963
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.48 |
| Max. Negotiated Rate |
$130.42 |
| Rate for Payer: Adventist Health Commercial |
$34.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.47
|
| Rate for Payer: Cash Price |
$78.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$117.73
|
| Rate for Payer: Heritage Provider Network Senior |
$117.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.48
|
| Rate for Payer: Multiplan Commercial |
$130.42
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
IP
|
$161.56
|
|
|
Service Code
|
NDC 67546-111-12
|
| Hospital Charge Code |
1711963
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.24 |
| Max. Negotiated Rate |
$121.17 |
| Rate for Payer: Adventist Health Commercial |
$32.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$110.99
|
| Rate for Payer: Cash Price |
$72.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.38
|
| Rate for Payer: Heritage Provider Network Senior |
$109.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.39
|
| Rate for Payer: Multiplan Commercial |
$121.17
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
OP
|
$173.90
|
|
|
Service Code
|
NDC 67546-111-14
|
| Hospital Charge Code |
1711963
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.48 |
| Max. Negotiated Rate |
$147.82 |
| Rate for Payer: Adventist Health Commercial |
$34.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$92.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$147.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$95.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$130.42
|
| Rate for Payer: Blue Shield of California Commercial |
$107.99
|
| Rate for Payer: Blue Shield of California EPN |
$102.08
|
| Rate for Payer: Cash Price |
$78.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.82
|
| Rate for Payer: Dignity Health Senior |
$147.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$111.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$107.64
|
| Rate for Payer: Heritage Provider Network Senior |
$107.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.48
|
| Rate for Payer: Multiplan Commercial |
$130.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$147.82
|
| Rate for Payer: Vantage Medical Group Senior |
$147.82
|
|
|
NITAZOXANIDE 500 MG TABLET [39254]
|
Facility
OP
|
$70.25
|
|
|
Service Code
|
NDC 64980-526-21
|
| Hospital Charge Code |
1711963
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$59.71 |
| Rate for Payer: Adventist Health Commercial |
$14.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$59.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$38.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.69
|
| Rate for Payer: Blue Shield of California Commercial |
$43.63
|
| Rate for Payer: Blue Shield of California EPN |
$41.24
|
| Rate for Payer: Cash Price |
$31.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.71
|
| Rate for Payer: Dignity Health Senior |
$59.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.48
|
| Rate for Payer: Heritage Provider Network Senior |
$43.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.56
|
| Rate for Payer: Multiplan Commercial |
$52.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.71
|
| Rate for Payer: Vantage Medical Group Senior |
$59.71
|
|
|
NITROFURANTOIN 25 MG/5 ML ORAL SUSPENSION [10723]
|
Facility
IP
|
$7.45
|
|
|
Service Code
|
NDC 16571-740-24
|
| Hospital Charge Code |
1715644
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$5.59 |
| Rate for Payer: Adventist Health Commercial |
$1.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.12
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.04
|
| Rate for Payer: Heritage Provider Network Senior |
$5.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$5.59
|
|
|
NITROFURANTOIN 25 MG/5 ML ORAL SUSPENSION [10723]
|
Facility
OP
|
$7.45
|
|
|
Service Code
|
NDC 16571-740-24
|
| Hospital Charge Code |
1715644
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.33 |
| Rate for Payer: Adventist Health Commercial |
$1.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.59
|
| Rate for Payer: Blue Shield of California Commercial |
$4.63
|
| Rate for Payer: Blue Shield of California EPN |
$4.37
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.33
|
| Rate for Payer: Dignity Health Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Senior |
$4.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$5.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.33
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
OP
|
$1.99
|
|
|
Service Code
|
NDC 68001-386-00
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.69
|
| Rate for Payer: Dignity Health Senior |
$1.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Vantage Medical Group Senior |
$1.69
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
IP
|
$2.82
|
|
|
Service Code
|
NDC 47781-308-01
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.94
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
OP
|
$3.45
|
|
|
Service Code
|
NDC 50268-624-11
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.93 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.93
|
| Rate for Payer: Dignity Health Senior |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.93
|
| Rate for Payer: Vantage Medical Group Senior |
$2.93
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
IP
|
$3.45
|
|
|
Service Code
|
NDC 50268-624-15
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.37
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.59
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
IP
|
$3.45
|
|
|
Service Code
|
NDC 50268-624-11
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.37
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.59
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
OP
|
$3.45
|
|
|
Service Code
|
NDC 50268-624-15
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.93 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.93
|
| Rate for Payer: Dignity Health Senior |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.93
|
| Rate for Payer: Vantage Medical Group Senior |
$2.93
|
|
|
NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]
|
Facility
OP
|
$2.82
|
|
|
Service Code
|
NDC 47781-308-01
|
| Hospital Charge Code |
1711101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.66
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.40
|
| Rate for Payer: Dignity Health Senior |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Vantage Medical Group Senior |
$2.40
|
|
