|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 68084-676-01
|
| Hospital Charge Code |
1710529
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 68084-676-01
|
| Hospital Charge Code |
1710529
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 51079-888-01
|
| Hospital Charge Code |
1710529
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 51079-888-20
|
| Hospital Charge Code |
1710529
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-2203-05
|
| Hospital Charge Code |
1710529
|
|
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 |
$0.04
|
| 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
|
|
|
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77725]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0121-0576-16
|
| Hospital Charge Code |
1715482
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77725]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0121-0576-16
|
| Hospital Charge Code |
1715482
|
|
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 |
$0.04
|
| 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
|
|
|
METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
CPT J2765
|
| Hospital Charge Code |
1720223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Cigna of CA 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 |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.99
|
|
|
METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
CPT J2765
|
| Hospital Charge Code |
1720223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.99
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 51079-886-01
|
| Hospital Charge Code |
1711784
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 51079-886-20
|
| Hospital Charge Code |
1711784
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 51079-886-20
|
| Hospital Charge Code |
1711784
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0093-2204-01
|
| Hospital Charge Code |
1711784
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.07
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 51079-886-01
|
| Hospital Charge Code |
1711784
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.68
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0093-2204-01
|
| Hospital Charge Code |
1711784
|
|
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 |
$0.04
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
METOLAZONE 10 MG TABLET [10586]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 76385-138-01
|
| Hospital Charge Code |
1711263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.81
|
|
|
METOLAZONE 10 MG TABLET [10586]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 0185-5600-01
|
| Hospital Charge Code |
1711263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.81
|
|
|
METOLAZONE 10 MG TABLET [10586]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 76385-138-01
|
| Hospital Charge Code |
1711263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.81
|
|
|
METOLAZONE 10 MG TABLET [10586]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 72888-054-01
|
| Hospital Charge Code |
1711263
|
|
Hospital Revenue Code
|
259
|
| 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 Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| 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 |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
METOLAZONE 10 MG TABLET [10586]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 72888-054-01
|
| Hospital Charge Code |
1711263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.36
|
|
|
METOLAZONE 10 MG TABLET [10586]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 0185-5600-01
|
| Hospital Charge Code |
1711263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.81
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 0185-5050-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 76385-136-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.59
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
|
IP
|
$1.99
|
|
|
Service Code
|
NDC 62332-532-31
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.49
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
NDC 51079-023-20
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.47
|
|
