|
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [120961]
|
Facility
|
IP
|
$12.50
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.88
|
| Rate for Payer: Multiplan Commercial |
$9.38
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [120961]
|
Facility
|
OP
|
$12.50
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.50
|
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.88
|
| Rate for Payer: Multiplan Commercial |
$9.38
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION [120960]
|
Facility
|
IP
|
$7.76
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$6.21 |
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION [120960]
|
Facility
|
OP
|
$7.76
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$6.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.66
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION [120962]
|
Facility
|
IP
|
$56.86
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.27 |
| Max. Negotiated Rate |
$45.49 |
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$34.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.27
|
| Rate for Payer: Multiplan Commercial |
$42.65
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION [120962]
|
Facility
|
OP
|
$56.86
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.27 |
| Max. Negotiated Rate |
$45.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$34.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$34.12
|
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$34.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$34.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.27
|
| Rate for Payer: Multiplan Commercial |
$42.65
|
|
|
METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [118363]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 45802-174-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [118363]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 45802-174-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [118363]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 4116706003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [118363]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 4116706003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [118363]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 41167-0600-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [118363]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 41167-0600-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
METOCLOPRAMIDE 10 MG/10 ML ORAL SOLUTION [40877725]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 0121-1576-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
METOCLOPRAMIDE 10 MG/10 ML ORAL SOLUTION [40877725]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 0121-1576-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-2203-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0093-2203-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 51079-888-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 51079-888-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 51079-888-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 51079-888-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-2203-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0093-2203-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77725]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0576-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77725]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0576-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
