|
METRONIDAZOLE 500 MG TABLET [5016]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 60687-550-11
|
| Hospital Charge Code |
1710196
|
|
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
|
|
|
METRONIDAZOLE 500 MG TABLET [5016]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 50111-334-02
|
| Hospital Charge Code |
1710196
|
|
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 |
$0.26
|
| 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
|
|
|
METRONIDAZOLE 500 MG TABLET [5016]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68001-365-00
|
| Hospital Charge Code |
1710196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.46
|
|
|
METRONIDAZOLE (BULK) POWDER [5017]
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 38779-0146-8
|
| Hospital Charge Code |
NDG5017B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.70
|
|
|
METRONIDAZOLE (BULK) POWDER [5017]
|
Facility
|
OP
|
$5.20
|
|
|
Service Code
|
NDC 62991-1685-3
|
| Hospital Charge Code |
NDG5017B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.12
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.90
|
|
|
METRONIDAZOLE (BULK) POWDER [5017]
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 38779-0146-8
|
| Hospital Charge Code |
NDG5017B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.96
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.70
|
|
|
METRONIDAZOLE (BULK) POWDER [5017]
|
Facility
|
IP
|
$5.20
|
|
|
Service Code
|
NDC 62991-1685-3
|
| Hospital Charge Code |
NDG5017B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.90
|
|
|
METRONIDAZOLE ORAL SUSPENSION COMPOUND 50 MG/ML [4080303]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 9994-0803-03
|
| Hospital Charge Code |
1715624
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
METRONIDAZOLE ORAL SUSPENSION COMPOUND 50 MG/ML [4080303]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 9994-0803-03
|
| Hospital Charge Code |
1715624
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
METYRAPONE 250 MG CAPSULE [21867]
|
Facility
|
IP
|
$48.31
|
|
|
Service Code
|
NDC 76336-455-18
|
| Hospital Charge Code |
1710525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.57 |
| Max. Negotiated Rate |
$38.65 |
| Rate for Payer: Cash Price |
$21.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$36.23
|
|
|
METYRAPONE 250 MG CAPSULE [21867]
|
Facility
|
OP
|
$48.31
|
|
|
Service Code
|
NDC 76336-455-18
|
| Hospital Charge Code |
1710525
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.57 |
| Max. Negotiated Rate |
$36.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.99
|
| Rate for Payer: Cash Price |
$21.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$36.23
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
NDC 0093-8739-01
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.16
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 0527-4107-37
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.70
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
OP
|
$1.55
|
|
|
Service Code
|
NDC 0093-8739-01
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.16
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 50742-239-01
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 0527-4107-37
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.70
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 50742-239-01
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| 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: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 50742-240-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.45
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0093-8740-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.13
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.42
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0093-8740-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.42
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 62756-956-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.06
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 62756-956-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.85
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.06
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 50742-240-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.45
|
|
|
MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0816-49
|
| Hospital Charge Code |
NDC4081649
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0816-49
|
| Hospital Charge Code |
NDC4081649
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
