|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-12
|
| Hospital Charge Code |
NDG4749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-12
|
| Hospital Charge Code |
NDG4749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0990-7715-02
|
| Hospital Charge Code |
NDG4749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]
|
Facility
|
OP
|
$105.14
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
1720158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.83 |
| Max. Negotiated Rate |
$78.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$63.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$63.08
|
| Rate for Payer: Cash Price |
$47.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$63.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$63.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.86
|
|
|
MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]
|
Facility
|
IP
|
$105.14
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
1720158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.83 |
| Max. Negotiated Rate |
$84.11 |
| Rate for Payer: Cash Price |
$47.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$63.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.86
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 50268-522-11
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 68084-490-01
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 68084-490-11
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 68084-490-11
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 50268-522-15
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 68084-490-01
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 50268-522-15
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 50268-522-11
|
| Hospital Charge Code |
1710509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.54
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 59746-121-06
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 16571-661-01
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-01
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-11
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 16571-661-01
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-01
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 68084-491-01
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 68084-491-11
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 59746-121-06
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-730-11
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 68084-491-11
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
MECLIZINE 25 MG TABLET [12025]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 68084-491-01
|
| Hospital Charge Code |
1710521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
