|
METHADONE 10 MG/ML INJECTION SOLUTION [10546]
|
Facility
|
IP
|
$21.60
|
|
|
Service Code
|
NDC 17478-380-20
|
| Hospital Charge Code |
NDG10546
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.20
|
|
|
METHADONE 10 MG/ML INJECTION SOLUTION [10546]
|
Facility
|
OP
|
$21.60
|
|
|
Service Code
|
NDC 17478-380-20
|
| Hospital Charge Code |
NDG10546
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.96
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.20
|
|
|
METHADONE 10 MG/ML INTRAVENOUS SYRINGE [153564]
|
Facility
|
OP
|
$21.60
|
|
|
Service Code
|
CPT J1230
|
| Hospital Charge Code |
1730057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.96
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.20
|
|
|
METHADONE 10 MG/ML INTRAVENOUS SYRINGE [153564]
|
Facility
|
IP
|
$21.60
|
|
|
Service Code
|
CPT J1230
|
| Hospital Charge Code |
1730057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.20
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
|
|
METHADONE 10 MG TABLET [4953]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1730034
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
METHADONE 10 MG TABLET [4953]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1730034
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
METHADONE 1 MG/ML ORAL SOLN UD [4080790]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1734060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 1 MG/ML ORAL SOLN UD [4080790]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1734063
|
|
Hospital Revenue Code
|
636
|
| 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 |
$0.04
|
| 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 1 MG/ML ORAL SOLN UD [4080790]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1734060
|
|
Hospital Revenue Code
|
636
|
| 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 |
$0.04
|
| 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 1 MG/ML ORAL SOLN UD [4080790]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1734063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 5 MG/5 ML ORAL SOLUTION [4952]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1734063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| 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: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| 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: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 5 MG/5 ML ORAL SOLUTION [4952]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
NDG4952
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 5 MG/5 ML ORAL SOLUTION [4952]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1734063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 5 MG/5 ML ORAL SOLUTION [4952]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
NDG4952
|
|
Hospital Revenue Code
|
636
|
| 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 |
$0.04
|
| 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
METHADONE 5 MG TABLET [4954]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1730031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| 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: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
METHADONE 5 MG TABLET [4954]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
CPT S0109
|
| Hospital Charge Code |
1730031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
METHENAMINE HIPPURATE 1 GRAM TABLET [10549]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 60687-694-21
|
| Hospital Charge Code |
1712025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.22
|
|
|
METHENAMINE HIPPURATE 1 GRAM TABLET [10549]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 65862-782-01
|
| Hospital Charge Code |
1712025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.72 |
| 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 |
$0.43
|
| 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 Beech St/Commercial/PHCS |
$0.72
|
|
|
METHENAMINE HIPPURATE 1 GRAM TABLET [10549]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 65862-782-01
|
| Hospital Charge Code |
1712025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.72
|
|
|
METHENAMINE HIPPURATE 1 GRAM TABLET [10549]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 60687-694-21
|
| Hospital Charge Code |
1712025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.22
|
|
|
METHENAMINE HIPPURATE 1 GRAM TABLET [10549]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 60687-694-11
|
| Hospital Charge Code |
1712025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.22
|
|
|
METHENAMINE HIPPURATE 1 GRAM TABLET [10549]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 60687-694-11
|
| Hospital Charge Code |
1712025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.22
|
|
|
METHENAMINE MANDELATE 1 GRAM TABLET [4966]
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 42799-106-01
|
| Hospital Charge Code |
1710122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.25
|
|
|
METHENAMINE MANDELATE 1 GRAM TABLET [4966]
|
Facility
|
OP
|
$1.67
|
|
|
Service Code
|
NDC 42799-106-01
|
| Hospital Charge Code |
1710122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.25
|
|
|
METHENAMINE MANDELATE 1 GRAM TABLET [4966]
|
Facility
|
IP
|
$2.37
|
|
|
Service Code
|
NDC 13925-107-01
|
| Hospital Charge Code |
1710122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.78
|
|
