|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 6068718411
|
| 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 |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| 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 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6068718457
|
| 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: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 3334229809
|
| 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 |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| 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 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0832111360
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6068717357
|
| 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 |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| 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
|
$0.24
|
|
|
Service Code
|
NDC 4733532186
|
| 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 |
$0.11
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| 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
|
$0.24
|
|
|
Service Code
|
NDC 4733532186
|
| 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 |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| 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
|
$0.20
|
|
|
Service Code
|
NDC 3334229709
|
| 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 |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 6068717357
|
| 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 |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| 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
|
$0.19
|
|
|
Service Code
|
NDC 7257800305
|
| 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 |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| 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
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 7257800305
|
| 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 |
$0.09
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| 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
|
$0.58
|
|
|
Service Code
|
NDC 6068717311
|
| 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 |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| 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
|
$0.20
|
|
|
Service Code
|
NDC 3334229709
|
| 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 |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6068717311
|
| 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 |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| 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
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$601.34
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$1,680.62 |
| Rate for Payer: Adventist Health Commercial |
$120.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,680.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$489.56
|
| Rate for Payer: Blue Shield of California Commercial |
$268.35
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna of CA HMO |
$420.94
|
| Rate for Payer: Cigna of CA PPO |
$420.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$511.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$420.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.54
|
| Rate for Payer: EPIC Health Plan Senior |
$240.54
|
| Rate for Payer: Galaxy Health WC |
$511.14
|
| Rate for Payer: Global Benefits Group Commercial |
$360.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$428.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$381.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$484.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$354.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$420.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$420.94
|
| Rate for Payer: Multiplan Commercial |
$481.07
|
| Rate for Payer: Networks By Design Commercial |
$300.67
|
| Rate for Payer: Prime Health Services Commercial |
$511.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$360.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$360.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.68
|
| Rate for Payer: United Healthcare All Other HMO |
$219.67
|
| Rate for Payer: United Healthcare HMO Rider |
$214.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.14
|
| Rate for Payer: Vantage Medical Group Senior |
$511.14
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$601.34
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$511.14 |
| Rate for Payer: Adventist Health Commercial |
$120.27
|
| Rate for Payer: Blue Shield of California Commercial |
$304.88
|
| Rate for Payer: Blue Shield of California Commercial |
$462.43
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna of CA HMO |
$420.94
|
| Rate for Payer: Cigna of CA PPO |
$420.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$420.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.54
|
| Rate for Payer: EPIC Health Plan Senior |
$240.54
|
| Rate for Payer: Galaxy Health WC |
$511.14
|
| Rate for Payer: Global Benefits Group Commercial |
$360.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$381.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$354.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.32
|
| Rate for Payer: Multiplan Commercial |
$481.07
|
| Rate for Payer: Networks By Design Commercial |
$300.67
|
| Rate for Payer: Prime Health Services Commercial |
$511.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.68
|
| Rate for Payer: United Healthcare All Other HMO |
$219.67
|
| Rate for Payer: United Healthcare HMO Rider |
$214.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.94
|
|
|
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 |
$42.23
|
| Rate for Payer: Blue Shield of California Commercial |
$162.37
|
| Rate for Payer: Blue Shield of California Commercial |
$154.53
|
| Rate for Payer: Blue Shield of California Commercial |
$234.39
|
| Rate for Payer: Blue Shield of California Commercial |
$107.05
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA HMO |
$147.81
|
| Rate for Payer: Cigna of CA PPO |
$147.81
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$213.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Senior |
$84.46
|
| Rate for Payer: EPIC Health Plan Senior |
$121.92
|
| Rate for Payer: Galaxy Health WC |
$179.48
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Global Benefits Group Commercial |
$126.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$134.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$193.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$124.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$179.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.15
|
| Rate for Payer: Multiplan Commercial |
$168.92
|
| Rate for Payer: Multiplan Commercial |
$243.84
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Networks By Design Commercial |
$105.58
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Prime Health Services Commercial |
$179.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$79.24
|
| 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 |
$77.13
|
| Rate for Payer: United Healthcare HMO Rider |
$75.47
|
| Rate for Payer: United Healthcare HMO Rider |
$108.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$69.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.82
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
OP
|
$211.15
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.23 |
| Max. Negotiated Rate |
$1,181.60 |
| Rate for Payer: Adventist Health Commercial |
$42.23
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,181.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,181.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$179.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$158.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$193.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$193.91
|
| Rate for Payer: Blue Shield of California Commercial |
$188.67
|
| Rate for Payer: Blue Shield of California Commercial |
$188.67
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA HMO |
$147.81
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$147.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$179.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$259.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$179.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$213.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.46
|
| 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 |
$84.46
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Galaxy Health WC |
$179.48
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Global Benefits Group Commercial |
$126.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$303.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$303.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$134.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$193.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$342.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$342.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$179.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$124.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$147.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$213.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$147.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$213.36
|
| Rate for Payer: Multiplan Commercial |
$243.84
|
| Rate for Payer: Multiplan Commercial |
$168.92
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Networks By Design Commercial |
$105.58
|
| Rate for Payer: Prime Health Services Commercial |
$179.48
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$182.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$182.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$79.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Other HMO |
$77.13
|
| 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 |
$75.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$69.15
|
| 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 |
$179.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$179.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$179.48
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$12,236.21
|
|
|
Service Code
|
APR-DRG 5322
|
| Min. Negotiated Rate |
$9,772.87 |
| Max. Negotiated Rate |
$12,236.21 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,772.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,236.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,948.19
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$38,082.29
|
|
|
Service Code
|
APR-DRG 5324
|
| Min. Negotiated Rate |
$30,415.72 |
| Max. Negotiated Rate |
$38,082.29 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30,415.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38,082.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34,073.63
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$17,688.11
|
|
|
Service Code
|
APR-DRG 5323
|
| Min. Negotiated Rate |
$14,127.21 |
| Max. Negotiated Rate |
$17,688.11 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,127.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17,688.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15,826.20
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$9,041.19
|
|
|
Service Code
|
APR-DRG 5321
|
| Min. Negotiated Rate |
$7,221.05 |
| Max. Negotiated Rate |
$9,041.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,221.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9,041.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,089.48
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$97,127.53
|
|
|
Service Code
|
MSDRG 760
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$97,127.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30,543.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$97,127.53
|
| Rate for Payer: EPIC Health Plan Senior |
$64,751.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,865.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82,411.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78,879.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$89,373.04
|
|
|
Service Code
|
MSDRG 761
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$89,373.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17,267.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$89,373.04
|
| Rate for Payer: EPIC Health Plan Senior |
$59,582.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54,165.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$75,831.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72,581.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$12,109.31
|
|
|
Service Code
|
APR-DRG 7401
|
| Min. Negotiated Rate |
$9,671.51 |
| Max. Negotiated Rate |
$12,109.31 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,671.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,109.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,834.64
|
|
