|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$64.50
|
|
|
Service Code
|
NDC 43386-140-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$48.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$38.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$38.70
|
| Rate for Payer: Cash Price |
$29.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$38.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$48.38
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$23.83
|
|
|
Service Code
|
NDC 0093-3655-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$17.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.30
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$17.87
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$23.83
|
|
|
Service Code
|
NDC 0093-3655-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$19.06 |
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$17.87
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$64.50
|
|
|
Service Code
|
NDC 43386-140-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$51.60 |
| Rate for Payer: Cash Price |
$29.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$38.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$48.38
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$19.80
|
|
|
Service Code
|
NDC 69238-1605-2
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$14.85 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.88
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.85
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE [154475]
|
Facility
|
IP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
NDG154575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.24 |
| Max. Negotiated Rate |
$246.16 |
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$246.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$184.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$230.78
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE [154475]
|
Facility
|
OP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
NDG154575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.24 |
| Max. Negotiated Rate |
$230.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$184.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$184.62
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$184.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$184.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$230.78
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS WRAP [40891651]
|
Facility
|
IP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
1720998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.24 |
| Max. Negotiated Rate |
$246.16 |
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$246.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$184.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$230.78
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS WRAP [40891651]
|
Facility
|
OP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
1720998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.24 |
| Max. Negotiated Rate |
$230.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$184.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$184.62
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$184.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$184.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$230.78
|
|
|
METHYLPHENIDATE 10 MG TABLET [4986]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 16729-479-01
|
| Hospital Charge Code |
1730103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
METHYLPHENIDATE 10 MG TABLET [4986]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16729-479-01
|
| Hospital Charge Code |
1730103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
OP
|
$1.87
|
|
|
Service Code
|
NDC 0078-0441-05
|
| Hospital Charge Code |
1730104
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.12
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.40
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
IP
|
$1.87
|
|
|
Service Code
|
NDC 0078-0441-05
|
| Hospital Charge Code |
1730104
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.40
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 0115-1800-01
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 0115-1800-01
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 68084-805-21
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.50
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 68084-805-21
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.50
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
NDC 50458-585-01
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Cash Price |
$6.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.61
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$9.34
|
|
|
Service Code
|
NDC 10147-0685-1
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.00
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
NDC 9999-7068-51
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.00
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$6.22
|
|
|
Service Code
|
NDC 62175-310-37
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.66
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
NDC 50458-585-01
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$11.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.29
|
| Rate for Payer: Cash Price |
$6.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.61
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
NDC 10147-0685-1
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.00
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$6.22
|
|
|
Service Code
|
NDC 62175-310-37
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.73
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.66
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$9.34
|
|
|
Service Code
|
NDC 9999-7068-51
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.00
|
|
