|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
|
OP
|
$310.20
|
|
|
Service Code
|
HCPCS J2265
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.61 |
| Max. Negotiated Rate |
$248.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$186.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$186.12
|
| Rate for Payer: Cash Price |
$170.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$248.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$186.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$186.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$170.61
|
| Rate for Payer: Multiplan Commercial |
$232.65
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 0591-5694-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 0591-5694-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.46
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
OP
|
$15.91
|
|
|
Service Code
|
NDC 70710-1159-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.55
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
OP
|
$15.91
|
|
|
Service Code
|
NDC 68180-151-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.55
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
IP
|
$15.91
|
|
|
Service Code
|
NDC 70710-1159-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
IP
|
$15.91
|
|
|
Service Code
|
NDC 68180-151-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 57237-011-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 57237-011-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 0904-6519-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 0904-6519-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
