|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 72578-003-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 47335-321-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 47335-321-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 33342-297-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 72578-003-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 33342-297-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$567.30
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.46 |
| Max. Negotiated Rate |
$482.20 |
| Rate for Payer: Adventist Health Commercial |
$113.46
|
| Rate for Payer: Blue Shield of California Commercial |
$418.67
|
| Rate for Payer: Blue Shield of California EPN |
$275.71
|
| Rate for Payer: Cash Price |
$312.02
|
| Rate for Payer: Cigna of CA HMO |
$397.11
|
| Rate for Payer: Cigna of CA PPO |
$397.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.92
|
| Rate for Payer: EPIC Health Plan Senior |
$226.92
|
| Rate for Payer: Galaxy Health WC |
$482.20
|
| Rate for Payer: Global Benefits Group Commercial |
$340.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$378.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$216.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$351.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.15
|
| Rate for Payer: Multiplan Commercial |
$453.84
|
| Rate for Payer: Networks By Design Commercial |
$283.65
|
| Rate for Payer: Prime Health Services Commercial |
$482.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$212.91
|
| Rate for Payer: United Healthcare All Other HMO |
$207.23
|
| Rate for Payer: United Healthcare HMO Rider |
$202.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$185.79
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$567.30
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.46 |
| Max. Negotiated Rate |
$643.80 |
| Rate for Payer: Adventist Health Commercial |
$113.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$372.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$482.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$312.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$425.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$643.80
|
| Rate for Payer: Blue Shield of California Commercial |
$268.35
|
| Rate for Payer: Blue Shield of California EPN |
$268.35
|
| Rate for Payer: Cash Price |
$312.02
|
| Rate for Payer: Cash Price |
$312.02
|
| Rate for Payer: Cigna of CA HMO |
$397.11
|
| Rate for Payer: Cigna of CA PPO |
$397.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$482.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$482.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$482.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.92
|
| Rate for Payer: EPIC Health Plan Senior |
$226.92
|
| Rate for Payer: Galaxy Health WC |
$482.20
|
| Rate for Payer: Global Benefits Group Commercial |
$340.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$404.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$378.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$457.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$351.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$397.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$397.11
|
| Rate for Payer: Multiplan Commercial |
$453.84
|
| Rate for Payer: Networks By Design Commercial |
$283.65
|
| Rate for Payer: Prime Health Services Commercial |
$482.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$340.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$340.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$212.91
|
| Rate for Payer: United Healthcare All Other HMO |
$207.23
|
| Rate for Payer: United Healthcare HMO Rider |
$202.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$185.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$482.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$482.20
|
| Rate for Payer: Vantage Medical Group Senior |
$482.20
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-03
|
| Min. Negotiated Rate |
$79.68 |
| Max. Negotiated Rate |
$338.63 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$261.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$219.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$298.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$244.65
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: Cigna of CA HMO |
$254.97
|
| Rate for Payer: Cigna of CA PPO |
$294.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$338.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$338.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.36
|
| Rate for Payer: EPIC Health Plan Senior |
$159.36
|
| Rate for Payer: Galaxy Health WC |
$338.63
|
| Rate for Payer: Global Benefits Group Commercial |
$239.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$151.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$246.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$278.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$278.87
|
| Rate for Payer: Multiplan Commercial |
$318.71
|
| Rate for Payer: Networks By Design Commercial |
$258.95
|
| Rate for Payer: Prime Health Services Commercial |
$338.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$239.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$239.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$199.19
|
| Rate for Payer: United Healthcare All Other HMO |
$199.19
|
| Rate for Payer: United Healthcare HMO Rider |
$199.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$199.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$338.63
|
| Rate for Payer: Vantage Medical Group Senior |
$338.63
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-30
|
| Min. Negotiated Rate |
$79.68 |
| Max. Negotiated Rate |
$338.63 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.36
|
| Rate for Payer: EPIC Health Plan Senior |
$159.36
|
| Rate for Payer: Galaxy Health WC |
$338.63
|
| Rate for Payer: Global Benefits Group Commercial |
$239.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$151.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$246.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.61
|
| Rate for Payer: Multiplan Commercial |
$318.71
|
| Rate for Payer: Networks By Design Commercial |
$258.95
|
| Rate for Payer: Prime Health Services Commercial |
$338.63
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-30
|
| Min. Negotiated Rate |
$79.68 |
| Max. Negotiated Rate |
$338.63 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$261.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$219.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$298.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$244.65
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: Cigna of CA HMO |
$254.97
|
| Rate for Payer: Cigna of CA PPO |
$294.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$338.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$338.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.36
|
| Rate for Payer: EPIC Health Plan Senior |
$159.36
|
| Rate for Payer: Galaxy Health WC |
$338.63
|
| Rate for Payer: Global Benefits Group Commercial |
$239.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$151.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$246.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$278.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$278.87
|
| Rate for Payer: Multiplan Commercial |
$318.71
|
| Rate for Payer: Networks By Design Commercial |
$258.95
|
| Rate for Payer: Prime Health Services Commercial |
$338.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$239.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$239.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$199.19
|
| Rate for Payer: United Healthcare All Other HMO |
$199.19
|
| Rate for Payer: United Healthcare HMO Rider |
$199.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$199.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$338.63
|
| Rate for Payer: Vantage Medical Group Senior |
$338.63
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-03
|
| Min. Negotiated Rate |
$79.68 |
| Max. Negotiated Rate |
$338.63 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.36
|
| Rate for Payer: EPIC Health Plan Senior |
$159.36
|
| Rate for Payer: Galaxy Health WC |
$338.63
|
| Rate for Payer: Global Benefits Group Commercial |
$239.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$151.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$246.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.61
|
| Rate for Payer: Multiplan Commercial |
$318.71
|
| Rate for Payer: Networks By Design Commercial |
$258.95
|
| Rate for Payer: Prime Health Services Commercial |
$338.63
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
OP
|
$199.20
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.84 |
| Max. Negotiated Rate |
$452.63 |
| Rate for Payer: Adventist Health Commercial |
$39.84
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$199.92
|
| Rate for Payer: Aetna of CA HMO/PPO |
$130.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$169.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$109.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$452.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$452.63
|
| Rate for Payer: Blue Shield of California Commercial |
$188.67
|
| Rate for Payer: Blue Shield of California Commercial |
$188.67
|
| Rate for Payer: Blue Shield of California EPN |
$188.67
|
| Rate for Payer: Blue Shield of California EPN |
$188.67
|
| Rate for Payer: Cash Price |
$109.56
|
| Rate for Payer: Cash Price |
$167.64
|
| Rate for Payer: Cash Price |
$109.56
|
| Rate for Payer: Cash Price |
$167.64
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA HMO |
$139.44
|
| Rate for Payer: Cigna of CA PPO |
$139.44
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$169.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$169.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$259.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Senior |
$121.92
|
| Rate for Payer: EPIC Health Plan Senior |
$79.68
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Galaxy Health WC |
$169.32
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Global Benefits Group Commercial |
$119.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$283.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$283.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$132.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$320.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$320.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$188.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$123.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$139.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$213.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$213.36
|
| Rate for Payer: Multiplan Commercial |
$243.84
|
| Rate for Payer: Multiplan Commercial |
$159.36
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Networks By Design Commercial |
$99.60
|
| Rate for Payer: Prime Health Services Commercial |
$169.32
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$119.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$182.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$119.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$182.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$74.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Other HMO |
$72.77
|
| Rate for Payer: United Healthcare All Other HMO |
$111.34
|
| Rate for Payer: United Healthcare HMO Rider |
$108.94
|
| Rate for Payer: United Healthcare HMO Rider |
$71.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$65.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$169.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$169.32
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
IP
|
$304.80
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$259.08 |
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Adventist Health Commercial |
$39.84
|
| Rate for Payer: Blue Shield of California Commercial |
$224.94
|
| Rate for Payer: Blue Shield of California Commercial |
$147.01
|
| Rate for Payer: Blue Shield of California EPN |
$96.81
|
| Rate for Payer: Blue Shield of California EPN |
$148.13
|
| Rate for Payer: Cash Price |
$167.64
|
| Rate for Payer: Cash Price |
$109.56
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA HMO |
$139.44
|
| Rate for Payer: Cigna of CA PPO |
$139.44
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Senior |
$79.68
|
| Rate for Payer: EPIC Health Plan Senior |
$121.92
|
| Rate for Payer: Galaxy Health WC |
$169.32
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Global Benefits Group Commercial |
$119.52
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$132.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$123.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$188.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.15
|
| Rate for Payer: Multiplan Commercial |
$159.36
|
| Rate for Payer: Multiplan Commercial |
$243.84
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Networks By Design Commercial |
$99.60
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Prime Health Services Commercial |
$169.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$74.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Other HMO |
$111.34
|
| Rate for Payer: United Healthcare All Other HMO |
$72.77
|
| Rate for Payer: United Healthcare HMO Rider |
$71.19
|
| Rate for Payer: United Healthcare HMO Rider |
$108.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$65.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.82
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 10135-701-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 10135-701-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0799-0001-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0799-0001-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.59
|
| Rate for Payer: Blue Shield of California Commercial |
$7.33
|
| Rate for Payer: Blue Shield of California EPN |
$7.33
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.67
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$2.75
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.01
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Vantage Medical Group Senior |
$4.67
|
|
|
MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.67
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$2.75
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.01
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
|
